THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

Dr.  Emil  Bogen 


•te-. 


o* 

\% 

LESSONS 


IN 


PHYSICAL  DIAGNOSIS. 


BY 

ALFRED  L.  LOOMIS,  M.D., 

PB0FZ8S0B    OF    THE    INSTlTnTES    AND    PRACTICE    OF    MEDICINE    IN    THE    MEDICAL    DI- 

PAETMENT    OF    THE    UNTVXRSITT    OF   NEW   YORK  ;    PHYSICIAN  TO 

BELLEVDE   AND    OUAEITT    HOSPITALS,  ETC. 


NEW  YORK  : 
ROBERT   M.   DE   WITT,    PUBLISHER, 

NO.    13    FEANKFOKT    STREET. 


Entered,  according  to  Act  of  Congress,  in  the  year  1868,  hj 

ROBERT    M.    DE    WITT, 

In  the  Clerk's  Office  of  the  District  Court  of  the  United  States  for  the  Southern  District  of 

New  York. 


Electrotyped  by  Printed  by 

Smith    <fc    MoDouoal,  The  New  York  Pbintinq  Co., 

82  &  84  Beekman  St.  81,  83  &  85  Center  St. 


m 


PREFAC  E 


In  compliance  with  the  request  frequently  made  by 
members  of  my  classes  in  Physical  Diagnosis  to  furnish 
them  a  guide  in  the  practice  of  this  art,  I  have  pre- 
pared the  following  lessons. 

Had   I   attempted   originality   on    such   a   subject,   I 

should  have  committed  error.     My  sole  object  has  been 

to   collect  into  a  plain  and  comprehensive  compend  the 

results  of  the  research  of  many  inquirers. 

A.  L.  L. 

249  West  23d  St.,  New  Yoek, 
May,  1868. 


CONTENTS. 


LESSON   I 

PHY     OF    THE    WaL 

Contents  op  the  Vakious  Regions 9 


Introduction. — Topography  of  the  "Walls   of   the   Chest. 


LESSON   II. 
Inspection,  Palpation,  Mensuration,  and  Succussion 16 

LESSON    III. 
Percussion 23 

LESSON   lY. 
Auscultation 33 

LESSON   V. 

Abnormal  or  Adventitious  Sounds 43 

LESSON   VI. 
Auscultation  of  the  Voice 50 

LESSON   VII. 

A  Synopsis  op  Physical  Signs  in  the  Diagnosis  op  Pulmonary 
Diseases '^^ 

LESSON    VIII. 

A  Synopsis  op  Physical  Signs  ln  the  Diagnosis  op  Pulmonary 

G4 
Diseases — Continued "^ 


Vi  CONTENTS. 

LESSON   IX. 

PAGS 

Topography  op  the  Heakt  and  Aorta — PHYsiOLOGicAii  Action 
OF  THE  Heart 79 

LESSON    X. 

Methods  op  Cardiac  Physical  Examination 87 

LESSON    XI. 
Abnormal  Sounds  op  the  Heart 95 

LESSON   XII. 

Synopsis  op  the  Physical  Signs  of  Pericarditis. — Hypertrophy, 
Dilatation,  and  Fatty  Pegener.vtion  of  Heart,  and 
Aneurisms  of  Thoracic  Aorta 109 

LESSON   XIII. 

Introduction. — Topography  op  the  Abdomen. — Contents  of  the 
Various  Regions.— Abdominal  Inspection,  Palpation,  Per- 
cussion, and  Auscultation. — Diseased  Conditions  of  the 
Peritoneum 119 

LESSON    XIV. 

Physical  Signs  op  the  Abnormal  Changes  in  the  Different 
Abdominal  Organs. — Stomach. — Intestines. — Liter. — Spleen  128 

LESSON    XY. 

Physical  Signs  op  the  Abnormal  Changes  in  the  Different 
Abdominal  Organs — Continued . .    143 


LUNGS, 


LESSON  I. 

Introduciion,—Topoffrap/iy    of   t?ie    Walls    of  the    Chest. -~ 
Contents  of  the  Various  Heffions, 

Gentlemen  • 

Physical  Diagnosis  is  a  term  used  to  designate  those 
methods  which  are  employed  for  detecting  disease  during 
life,  by  the  anatomical  changes  which  it  has  produced.  The 
nature  and  extent  of  such  changes  can  be  recognized  and  ap- 
preciated by  the  deviations  which  they  cause  in  the  affected 
organs  from  the  known  physical  condition  of  these  organs 
when  in  health.  The  significance  of  physical  signs  in  disease 
can  be  determined,  not  by  theory,  but  only  through  clinical 
observation  confirmed  by  examinations  after  death. 

There  are  six  methods  of  ehciting  these  physical  signs, 
termed  "physical  methods  of  diagnosis;"  viz.,  Inspection, 
Palpation,  3Iensuration,  Succussion,  Percussion,  and  Auscultation. 

The  most  important  of  these  are  Auscultation  and  Percussion. 
The  other  methods  are  only  subsidiary  to  these  two,  and  can 
seldom  be  regarded  as  furnishing  positive  evidence  of  disease. 
For  a  complete  and  accurate  physical  exploration,  you  must 
sometimes  employ  all  these  different  methods,  and  with  all, 
therefore,  you  should  become  familiar. 

In  order  to  localize  physical  signs,  the  chest  has  been 
divided  into  artificial  regions,  but  as  the  limits  of  these 
regions  are  arbitrary,  the  boundaries  adopted  by  different 
writers  vary.  The  following  divisions,  which  correspond  very 
nearly  to  those  proposed  by  many  authorities,  you  will  find,  I 
think,  sufficiently  small  and  well-defined  for  practical   pur- 


10  PHYSICAL  DIAGNOSIS. 

poses.  It  is  important  that  you  should  be  famihar,  not  only 
with  the  boundaries  of  these  regions,  but  with  the  relative 
position  of  the  structures  and  organs  or  portions  of  organs 
included  within  them. 

The  surface  of  the  chest  may  be  divided  into  three  general 
regions, — Anterior,  Posterior,  and  Lateral  The  Anterior  re- 
gion, on  either  side,  may  be  subdivided  into  Supra-Clavi- 
cular, Clavicular,  Infra-Clavicidar,  Mammarij,  and  Infra-Mam- 
manj.  Between  these  two  regions  we  have  the  Supra-Sternal, 
Superior  Sternal,  and  the  Inferior  Sternal.  The  Posterior 
region,  on  either  side,  may  be  subdivided  into  the  Siiperior 
Scapular,  Scapular,  and  Inferior  Scapular.  Between  these  you 
have  the  Inter- Scapular.  The  Lateral  region,  on  either  side, 
may  be  subdivided  into  Axillary,  and  Infra-Axillary  regions. 

The  Supra-Clavicular  region  is  a  triangle  whose  base  cor- 
responds to  the  trachea,  lower  side  to  the  clavicle,  upper  side 
to  a  line  drawn  from  the  outer  thhd  of  the  clavicle  to  the 
upper  rings  of  the  trachea.  This  region  contains,  on  either 
side,  the  apex  of  the  lung,  with  portions  of  the  subclavian  and 
carotid  arteries,  and  the  subclavian  and  jugular  veins. 

The  Clavicular  space  is  that  which  lies  behind  the  inner 
three-fifths  of  the  clavicle,  and  has  the  bone  for  its  boundary. 
It  is  occupied  on  both  sides  by  lung  tissue  ;  on  the  right  side, 
at  its  outer  extremity,  lies  the  subclavian  artery :  at  the 
stemo-clavicular  articulation,  the  arteria  innominata.  On  the 
left  side,  almost  at  right  angles  with  the  bone,  and  deeply 
seated,  are  the  carotid  and  subclavian  arteries. 

Tlie  Infra-Clavicular  region  has  for  its  boundaries,  the 
clavicle  above,  the  lower  border  of  the  third  rib  below,  the 
edge  of  the  sternum  inside,  and  outside  a  line  falling  verti- 
cally from  the  junction  of  the  middle  and  outer  third  of  the 
clavicle.  Within  these  hmits,  on  both  sides,  you  will  find  the 
superior  lobe  of  the  lung  and  the  main  bronchi ;  the  right 
bronchus  Hes  behind,  and  the  left  a  little  below  the  second 


MAMMARY  REGION. 


11 


costal  cartilage.  On  the  right  side,  close  to  the  sternal  border 
of  the  region,  He  the  superior  cava  and  a  portion  of  the  arch 
of  the  aorta ;  on  the  left,  a  portion  of  the  pulmonary  artery. 
The  aorta  and  pulmonary  artery  are  immediately  behind  the 
second  sterno-costal  articulation  ;  the  one  on  the  right,  the 


Fig.l. 


The  Anterior  Region,  the  Boundaries  of  its  Subdivisions,  and  the  Organs  Corresponding  to 
these  Subdivisions. 


other  on  the  left  side  of  the  sternum.  On  the  left  side  the 
lower  boundary  of  the  region  very  nearly  corresponds  to  the 
base  of  the  heart. 

The  Mammary  region  is  bounded  above  by  the  third  rib  ; 
below  by  the  inferior  margin  of  the  sixth  rib ;  inside  by  the 
edge  of  the  sternum ;  and  outside  by  a  vertical  line,  continu- 


12  PHYSICAL  DIAGNOSIS. 

OU3  ■with  the  outer  border  of  the  infra-clavicular  region.  Tou 
will  find  this  region  to  differ  materially  in  its  contents  on  the 
two  sides.  On  the  right  side  the  lung  is  found  extending  in 
front,  down  to  the  sixth  rib,  where  its  thin,  sharp  border  very 
nearly  corresponds  to  the  lower  boundary  of  the  region.  The 
right  wing  of  the  diaphragm,  though  not  attached  higher  than 
the  seventh  rib,  is  usually  pushed  up  by  the  liver  as  high  as 
the  fourth  interspace ;  a  portion  of  the  right  auricle  of  the 
heart,  and  the  superior  angle  of  the  right  ventricle,  lie  close 
to  the  sternum,  between  the  third  and  fifth  ribs.  On  the  left 
side,  the  lung  is  in  front  as  far  as  the  fourth  stemo-costal 
articulation,  where  its  anterior  border  passes  outwards,  until 
it  reaches  the  fifth  rib  (leaving  an  open  space  for  the  heart) ; 
then  it  crosses  forwards  and  downwards  as  far  as  the  sixth 
rib  ;  a  small  portion  of  the  apex  of  the  right  ventricle  is  also 
found  within  this  region. 

The  Infra-Mammary  region  is  bounded  above  by  the 
sixth  rib  ;  below  by  a  curved  line  corresponding  to  the  edges 
of  the  false  ribs ;  inside  by  the  inferior  portion  of  the  ster- 
num ;  and  outside  by  the  continuation  of  the  outer  boundary 
of  the  mammary  region.  This  region  contains,  on  the  right 
side,  the  liver,  with  a  portion  of  the  lung  in  front,  on  a  full 
iQspiration.  On  the  left,  lying  in  front,  near  the  median  hne, 
you  have  a  portion  of  the  left  lobe  of  the  lung,  the  stomach, 
and  the  anterior  border  of  the  spleen.  The  stomach  and 
spleen  usually  rise  to  a  level  with  the  sixth  rib. 

The  Supra-Sternal  region  is  the  space  which  lies  immedi- 
ately above  the  notch  of  the  sternum,  and  is  bounded  on 
either  side  by  the  stemo-mastoid  muscle.  It  is  occupied 
chiefly  by  the  trachea,  by  the  arteria  innominata  at  its  lower 
right  angle,  and  by  the  arch  of  the  aorta,  which  sometimes 
reaches  to  its  lower  border,  where,  on  firm  downward  pressure 
with  the  end  of  the  finger,  you  will  often  be  able  to  feel  it. 

The  Upper  Sternal  region  is  the  space  bounded  by  that 


INFEA-SCAPULAR  REGION.  jo 

portion  of  the  sternum  which  Hes  above  the  lower  margin  of 
the  third  rib.  In  this  region  the  lung  hes  in  front ;  immedi- 
ately behind  it  are  the  ascending  and  transverse  portions  of 
the  aorta,  and  the  pulmonary  artery  from  its  origin  to  its 
bifurcation.  The  pulmonary  valves  are  situated  close  to  the 
left  edge  of  the  sternum,  on  a  level  with  the  lower  margin  of 
the  third  rib.  The  aortic  valves  are  about  half  an  inch  lower 
down,  and  midway  between  the  median  line  and  the  left  edge 
of  the  sternum.  The  trachea  bifurcates  on  a  level  with  the 
second  ribs. 

The  Lo-wer  Sternal  region  corresponds  to  that  portion  of 
the  sternum  which  lies  below  the  lower  margin  of  the  third 
rib.  Throughout  the  whole  extent  of  this  region  on  the  right 
side,  the  lung  is  in  front ;  it  also  extends  down  on  the  left  side 
as  far  as  the  fourth  stemo-costal  articulation ;  below  this  lies 
the  greater  part  of  the  right  ventricle,  and  a  small  portion  of 
the  left.  The  mitral  valves  are  situated  close  to  the  left  edge 
of  the  sternum,  on  a  level  with  the  fourth  rib ;  the  tricuspid 
valve  is  nearer  the  median  hue,  and  is  more  superficial ;  infe- 
riorly  is  the  attachment  of  the  heart  to  the  diaphragm ;  be- 
low this  is  a  smaU  portion  of  the  Uver,  and  sometimes  of  the 
stomach. 

The  Supra-Scapular  and  Scapular  regions  together  oc- 
cupy the  space  from  the  second  to  the  seventh  rib,  and  are 
identical  in  their  outhnes  with  the  upper  and  lower  fossae  of 
the  scapula.     These  regions  are  occupied  by  lung  substance. 

The  Infra-Scapular  region  is  boimded  above  by  the  infe- 
rior angle  of  the  scapula  and  the  seventh  dorsal  vertebra ; 
below,  by  the  twelfth  rib ;  outside,  by  the  posterior  border  of 
the  lower  axillary  region;  and  inside  by  the  spinous  jDro- 
cesses  of  the  vertebrae.  Immediately  underneath  the  sur- 
face, as  far  as  the  eleventh  rib,  this  region  is  occupied  by  the 
lungs.  On  the  right  side  the  liver  extends  downwards  beyond 
the  level  of  the  eleventh  rib ;  on  the  left,  the  intestine  occu- 


u 


PHYSICAL  DIAGNOSIS. 

Fig.  2. 


The  Posterior  Jtegion,  the  Boundaries  of  its  Subdivisions,  and  the  Organs  Corresponding  to 
these  Subdivisions.— After  Sibson. 


INFRA-AXILLARY  REGION.  ng 

pies  the  inner  part  of  tliis  region,  and  the  spleen  the  outer. 
Close  to  the  spine,  on  each  side,— more  on  the  left  than  on  the 
right,— a  small  portion  of  the  kidney  is  found ;  along  the  left 
side  of  the  spine  runs  the  descending  aorta. 

The  Inter-Scapular  region  is  the  space  between  the  inner 
margin  of  the  scapula  and  the  spines  of  the  dorsal  vertebrge, 
from  the  second  to  the  sixth.  This  region  contains,  on  both 
sides,  lung  substance,  the  main  bronchi,  and  the  bronchial 
glands.  It  also  encloses  on  the  left  side  the  oesophagus,  and 
from  the  upper  part  of  the  fourth  dorsal  vertebra  do^vnwards, 
the  descending  aorta.  The  bifurcation  of  the  trachea  will  be 
found  opposite  the  third  dorsal  vertebra. 

The  Axillary  region  has  for  its  limits,  the  axilla,  above  ; 
below,  a  line  carried  backwards  from  the  lower  boundary  of 
the  mammary  region  to  the  inferior  angle  of  the  scapula ;  in 
front,  the  outer  margin  of  the  infra-clavicular  and  mammary 
regions ;  and  behind,  the  external  edge  of  the  scapula.  This 
region  corresponds  to  the  upper  lobes  of  the  lungs,  with  the 
main  bronchi  deeply  seated. 

The  Infra-Axillary  region  is  bounded  above  by  the  axil- 
lary region ;  anteriorly,  by  the  infi-a-mammary ;  posteriorly, 
by  the  infra-scapular ;  and  below  by  the  edges  of  the  false 
ribs.  This  region  contains,  on  both  sides,  the  lower  edge  of 
the  lung  sloping  downwards  and  backwards.  On  the  right 
Bide  is  the  liver,  and  on  the  left  the  stomach  and  spleen. 


LESSON  II. 

Inspection,  Palpation,  Me7isuration,  and  Succussion. 

Inspection  is  the  ocular  examination  of  tlie  external  sur- 
face. Though  usually  secondary  in  importance  to  Ausculta- 
tion and  Percussion,  it  should  not  be  lightly  regarded,  for  it 
often  furnishes  you  much  information  respecting  the  condition 
of  the  thoracic  and  abdominal  viscera.  By  Inspection  you 
recognize  changes  in  the  size,  form,  or  symmetry  of  these 
cavities,  and  in  the  movements  of  their  walls  during  respira- 
tion, as  regards  their  rhythm,  frequency,  or  force. 

As  students  of  anatomy  you  are  familiar  with  the  form  of  a 
well-proportioned  chest ;  a  description  of  it  is  therefore  un- 
necessary ;  suffice  it  to  say,  that  in  a  normal  state  the  two 
sides  are  symmetrical  in  every  part :  the  intercostal  spaces 
are  more  or  less  distinct,  according  as  the  individual  is  more 
or  less  fat.  In  quiet  respiration,  you  will  notice  the  abdomen 
rise  with  inspiration,  and  fall  with  expiration  ;  at  the  same 
time  you  wiU  observe  a  lateral  expansion  of  the  lower  ribs, 
and  a  slight  upward  movement  of  the  upper  part  of  the 
chest  with  inspiration,  and  a  downward  movement  with  expi- 
ration. The  movements  of  respiration  in  these  three  situa- 
tions are  called,  respectively,  abdominal,  inferior  costal,  and 
superior  costal  hreatldng.  In  the  female,  the  superior  costal 
breathing  is  most  marked.  In  the  male,  the  inferior  and 
abdominal. 

Considerable  alterations  in  the  form  and  movements  of  the 
chest  are  compatible  with  a  healthy  condition  of  the  thoracic 


INSPECTION.  17 

viscera.  You  rarely  meet  with  a  perfectly  symmetrical  chest, 
even  among  the  healthy.  In  my  examination  of  1,500  per- 
sons, I  found  only  one  well-proportioned,  symmetrical  chest  in 
seven.  As  you  can  easily  recognize  these  healthy  deviations 
from  symmetry,  I  shall  not  enter  into  details  concerning  them. 
I  would  however  mention  that  sUght  curvatures  of  the  spine, 
either  acquired  or  the  result  of  former  disease  of  the  verte- 
brae, cause  the  majority  of  these  deviations. 

We  will  first  consider  only  those  changes  in  the  size,  form, 
and  movements  of  the  thoracic  cavity  which  are  the  result  of 
disease  of  the  thoracic  organs ;  confining  ourselves  at  present 
to  the  lungs  and  pleurce.  The  readiest  way  of  presenting 
these  changes  to  you,  it  seems  to  me,  is  to  consider  them  as 
they  occur  in  the  different  thoracic  affections.  First,  we  will 
consider  the  signs  obtained  by  inspection  in  pleurisy ;  in  the 
first  stage,  prior  to  the  occurrence  of  much  hquid  effusion,  there 
is  no  apparent  change  in  the  size,  but  the  movements  of  the  af- 
fected side  are  diminished,  and  those  of  the  healthy  are  in- 
creased ;  you  have  what  is  termed  a  catching  respiration.  This 
sign  is  not  distinctive  of  pleurisy :  it  is  present  in  intercostal 
neuralgia,  and  in  pleurodynia.  In  the  stage  of  fluid  effusion,  if 
the  liquid  is  sufficient  to  compress  the  lung  and  dilate  the  tho- 
racic walls,  the  affected  side  will  be  increased  in  size,  and  in  pro- 
portion to  the  dilatation  its  movements  are  restricted  or  ar- 
rested. If  the  cavity  is  completely  filled  with  fluid,  there  wiU  be 
bulging  and  widening  of  the  intercostal  spaces,  with  more  or 
less  displacement  of  the  adjacent  viscera.  As  the  fluid  is  re- 
absorbed the  lung  expands,  but  not  to  the  same  volume  it  had 
before.  It  remains  more  or  less  contracted,  and  the  conse- 
quence is,  retraction  of  the  affected  side  from  atmospheric  pres- 
sure. Generally,  if  the  fluid  effusion  shall  have  existed  a  length 
of  time  previous  to  absorption,  the  subsequent  reti-action  is 
marked,  and  you  can  determine  at  once  by  inspection,  that 
pleurisy  has  existed  at  some  period  more  or  less  remote. 


13  PHYSICAL  DIAGNOSIS. 

In  Pulmonary  Emphysema,  if  it  is  a  well-marked  case,  on 
inspection  you  will  notice  a  dilatation  of  the  upper  portion  of 
the  chest,  while  its  whole  aspect  appears  more  rounded  than 
in  health,  so  that  it  has  received  the  name  "  barrel-shaped  " 
chest ;  the  shoulders  are  elevated  and  brought  forward,  the 
movements  in  respiration  are  limited  to  the  lower  portions  of 
the  chest  and  to  the  abdomen.  On  inspiration,  there  is  no 
outward  expansive  movement  of  the  ribs  ;  the  sternum  and 
ribs  seem  to  move  up  and  down  as  if  they  were  composed  of 
one  sohd  piece ;  in  some  cases  of  long  standing  you  will  have 
actual  falling  in  instead  of  expansion  of  lower  ribs  during 
inspiration.  In  a  well-marked  case  of  emphysema,  inspection 
is  quite  sufficient  for  a  diagnosis,  but  where  the  lungs  are  but 
slightly  emphysematous,  inspection  furnishes  no  positive  in- 
formation. In  pneumonia,  the  only  sign  furnished  by  inspec- 
tion is  that  the  movements  of  the  affected  side  are  restrained 
as  in  the  first  stage  of  jpleurisy.  In  phthisis  pulmonalis,  in- 
spection furnishes  you  important  information.  Depression  in 
the  infra-clavicular  region  on  the  affected  side  is  an  early  sign 
of  tubercular  deposit.  In  advanced  phthisis  the  depression  is 
still  more  marked,  in  some  instances  amounting  almost  to 
deformity.  The  expansive  movements  in  inspiration  on  the 
affected  side  in  the  infra-clavicular  region  are  diminished  or 
entirely  wanting,  and  this  want  of  expansion  is  often  notice- 
able at  a  very  early  period  in  the  disease. 

Bulging  or  partial  enlargement  of  the  chest,  determinable 
by  inspection,  occurs  in  various  affections.  Enlargement  of 
the  prsecordia  is  observed  in  certain  cases  of  hypertrophy  or 
dilatation  of  the  heart,  or  from  fluid  effusion  in  the  pericar- 
dium.   Bulging  occurs  also  over  aneurism al  and  other  tumors. 

In  cases  of  membranous  croup,  acute  and  chronic  laryngitis, 
and  oedema  glottidis,  inspection  will  disclose  to  you  the  seat  of 
the  obstruction  to  the  passage  of  air  to  the  lung  by  a  sinking 
ia  during  inspiration  of  the  parts  of  the  chest  which  yield 


PALPATION.  jg 

most  readily  to  atmospheric  pressure.  TMs  sinking  in  on 
inspii-ation  you  will  notice,  jfirst  in  the  supra-clavicular  spaces, 
then  in  the  infra-clavicular  spaces,  and  as  the  obstmction  in- 
creases, the  sternum  is  depressed  and  the  sides  contracted. 

Although  furnishing  few  positive  evidences  of  disease,  you 
should  always  employ  inspection  prior  to  the  other  methods 
of  physical  exploration.  This  is  important  in  all  cases  where 
the  evidences  furnished  by  the  other  physical  signs  are  not 
conclusive. 

Palpation,  or  the  act  of  laying  on  the  hand  and  feehng  the 
external  surface  of  the  body,  is  less  useful  than  inspection  in 
ascertaining  deformities,  and  the  amount  of  general  movement ; 
but  it  is  more  useful  in  determining  the  amount  of  local  expan- 
sion, and  the  character  of  vibration  or  impulses  communicated 
to  the  external  surface. 

In  order  to  arrive  at  satisfactory  results  from  its  employ- 
ment, you  should  observe  the  precautions  already  named  as 
influencing  accurate  inspection  ;  beyond  this,  I  need  only 
mention  that  in  thoracic  examinations  the  hand  or  the  fingers 
should  be  gently  and  evenly  applied  to  the  surface  of  the 
chest,  and  that  corresponding  portions  of  the  two  sides  of  the 
thorax  should  be  examined  simultaneously,  the  one  with  the 
right  hand,  and  the  other  with  the  left.  K  you  lay  your  hand 
lightly  upon  the  surface  of  the  chest  of  a  healthy  person  while 
speaking,  a  dehcate  tremulous  vibration  will  be  felt,  varying 
in  intensity  with  the  loudness  and  coarseness  of  the  voice  and 
the  lowness  of  its  pitch  ;  this  is  called  normal  vocal  fremitna. 
As  a  rule,  vocal  fremitus  is  more  marked  in  adults  than  in 
children,  in  males  than  in  females,  and  in  tliin  than  in  fat  per- 
sons. In  the  right  infra-clavicular  region  it  is  more  marked 
than  in  the  left.  Variations  in  the  vocal  fr-emitus  are  the  most 
important  evidences  of  disease  furnished  by  palpation  ;  in  fact 
aU  other  evidences  of  pulmonary  disease  afforded  by  palpation 
are  better  obtained  by  inspection. 


20  PHYSICAL  DIAGNOSIS. 

In  disease  the  normal  vocal  fremitus  may  be  increased, 
diminished,  or  entirely  absent. 

Increased  vocal  fremitus  occurs  in  those  affections  in  which 
lung  tissue  becomes  more  or  less  soHdified,  as  in  tuberculosis, 
pneumonia,  pulmonary  apoplexy,  and  oedema  of  the  lung. 
When  the  consolidation  is  extreme,  involving  bronchial  tubes 
of  considerable  size,  the  vocal  fremitus  may  be  diminished  or 
even  absent ;  while  increase  in  the  size  of  the  bronchial  tubes, 
with  the  slight  adjacent  consoHdation  met  with  in  chronic 
bronchitis,  often  gives  rise  to  increased  vocal  fremitus. 

Diminution  or  absence  of  the  normal  vocal  fremitus  occurs 
whenever  the  lung  substance  is  separated  from  the  chest  walls 
by  gaseous  or  liquid  accumulations  in  the  pleural  cavity,  as  in 
pneumo-thorax,  serous,  plastic,  hsemorrhagic,  or  purulent  pleu- 
ritic effusions.  In  vesicular  emj)hysema,  owing  to  the  dilated 
condition  of  the  air  cells,  vocal  fremitus  is  diminished.  Besides 
these  valuable  indications  furnished  by  vocal  fremitus,  you 
may  employ  palpation  to  detect  the  friction  caused  in  pleurisy 
by  the  rubbing  together  of  the  two  roughened  surfaces  of  the 
pleural  membrane,  and  which  is  termed  friction  fre^nitus. 

Sibilant  and  sonorous  rales  also  sometimes  throw  the  bron- 
chial tubes  into  vibration,  sufficiently  strong  to  be  felt  on  the 
surface  of  the  chest ;  this  is  termed  sonorous  or  rhoncMal frem- 
itus. Cavernous  gurgles  produced  in  excavations  near  the 
surface  may  be  accompanied  with  a  marked  fremitus. 

Mensuration  is  another  method  of  physical  exploration, 
employed  for  obtaining  information  similar  to  that  furnished 
by  inspection  and  palj)ation.  We  seldom  employ  it  in  physical 
examinations  of  the  lungs  unless  great  accuracy  is  requii'ed, 
as  in  the  record  of  cases.  The  instruments  which  have  been 
devised  for  the  measurement  of  the  chest  and  the  different 
lines  of  measurement  are  numerous.  The  circidar  measure- 
ment is  the  only  one  that  I  have  found  of  practical  value  in 
investigating   pulmonary  disease.      The  simplest   and   most 


MENSURATION.  21 

accurate  mode  of  measuring  the  circular  dimensions  of  the 
chest  is  by  means  of  the  instrument  devised  by  Dr.  Hare, 
which  consists  of  two  pieces  of  tape  similarly  graduated, 
joined  together,  and  padded  on  their  inner  surface  close  to  the 
line  of  junction  ;  the  saddle  thus  formed  when  placed  over  the 
spine  readily  adjusts  itseK  to  the  spinous  processes,  and  be- 
comes fixed  sufficiently  for  the  pui'pose  of  mensuration.  For 
comparing  the  expansive  movements  of  the  two  sides  you  will 
find  Dr.  Quain's  stethometer  very  useful.  The  object  of  the 
circular  measurement  of  the  chest  is  twofold — first,  to  ascer- 
tain the  comparative  bulk  of  the  two  sides  ;  second,  to  ascer- 
tain the  amount  of  expansion  and  retraction  accompanying 
inspiration  and  expiration  of  the  two  sides.  The  points  of 
measurement  are  the  spinous  processes  behind  and  the  median 
line  in  front,  on  the  level  of  the  sixth  costo-stemal  articula- 
tion. 

The  average  circular  dimension  of  the  chest  at  this  point  in 
1,500  healthy  persons  was  thirty-two  and  a  half  inches.  I  also 
found  in  these  examinations  that  about  four-fifths  of  healthy 
adults  have  irregularity  of  the  two  sides.  In  right-handed 
individuals  the  right  side  is  about  one-half  inch  larger  than 
the  left ;  in  left-handed,  the  left.     This  is  true  of  both  sexes. 

The  really  important  point  of  mensuration  in  pulmonary 
diseases,  is  the  comparison  of  the  two  sides  of  the  chest,  in 
rest  and  in  motion.  When  a  i^lem-al  cavity  is  distended  with 
air  or  fluid,  the  measurement  of  the  affected  side  may  exceed 
that  of  the  healthy  side,  by  two  or  three  inches ;  after  the 
removal  of  the  fluid,  there  may  be  an  equal  diminution  in  the 
measurement  of  the  affected  side,  as  compared  with  tho 
healthy  one. 

Deficiency  of  expansion  is  also  very  marked  in  certain  dis- 
eases. In  empyema,  for  instance,  you  will  often  find  the  total 
difference  between  the  fullest  inspiration  and  the  fullest  expi- 
ration on  the  affected  side  will  scarcely  exceed  one  sixteenth  of 


22  PHYSICAL  DIAGNOSIS. 

an  inch,  while  on  the  other  side,  there  may  be  a  difference  of 
two  or  three  inches. 

The  list  of  affections  in  which  variations  in  expansion  are 
to  be  estimated  by  measure  are  the  same  as  those  referred  to 
imder  the  head  of  Inspection. 

The  measurement  of  the  capacity  of  the  lungs  for  air, 
by  means  of  Dr.  Hutchinson's  spirometer,  or  of  the  "  vital 
capacity  of  the  chest,"  as  he  terms  it,  has  been  shown  by 
experience  to  be  very  unrehable,  and  his  instrument  has 
fallen  almost  entirely  into  disuse. 

Succussion,  as  a  method  of  physical  diagnosis,  is  almost 
exclusively  appHcable  to  the  diagnosis  of  a  single  disease ; 
viz.,  pneumo-hydrothorax.  It  is  performed  by  suddenly 
shaking  the  trunk  of  the  patient,  while  your  ear  is  apphed  to 
the  surface  of  the  chest ;  the  sound  produced  resembles  that ' 
perceived  on  shaking  a  bottle  partly  filled  with  water  close  to 
the  ear ;  it  is  a  gurgling,  sj^lashing  noise,  and  varies  in  tone 
with  the  density  of  the  fluid,  and  the  relative  quantities  of 
fluid  and  air  present.  It  is  almost  always  accomj)anied  by 
amphoric  respiration  and  metallic  tinkling.  I  shall  reserve  its 
further  consideration  until  I  detail  the  physical  signs  of 
pneumo-hydrothoras. 


LESSON    III. 

S^ercussion. 

Percussion,  as  a  means  of  diagnosis,  is  not  of  recent  date, 
for  we  find  it  mentioned  by  Hippocrates.  But  as  the  only 
mode  of  practising  it  was  by  striking  the  surface  itself  with 
the  tips  of  the  fingers,  or  knuckles,  now  termed  technically, 
immediate  percussion,  its  uses  were  very  Hniited.  Within  our 
time,  however,  M.  Piorry  gave  it  an  entirely  new  value  by 
introducing  mediate  percussion  ;  the  stroke  being  made,  not  on 
the  surface,  but  on  some  intervening  substance  applied  to  it ; 
and  he  so  demonstrated,  by  experiments  on  living  and  dead 
bodies,  its  superior  applicabiHty  for  determining  changes  in 
the  subjacent  parts,  that  mediate  percussion  ranks  now  only 
second  to  auscultation  among  the  methods  of  physical  explo- 
ration. 

To  estimate  the  value  of  percussion  and  to  understand  its 
true  significance,  you  must  first  learn  to  appreciate  correctly 
the  elements  of  sound.  Authors  have  employed  a  variety  of 
terms  to  designate  them,  such  as  clearness,  dulness,  empti- 
ness, fulness,  etc. ;  but  I  think,  that  a  classification  based 
upon  analysis  of  the  elements  of  sound  in  general,  will  afford 
us  the  truest  and  most  practical  distinctions,  especially  in 
estimating  the  sounds  in  thoracic  percussion.  Those  elements 
or  acoustic  properties  of  percussion  sounds  which  concern  us 
clinically  are  termed,  respectively,  Intensitij,  Pilch,  Quality,  and 
Duration,  of  which  Pitch  ranks  first  in  importance. 

The  Intensity  of  a  percussion  sound  may  be  increased  or 
diminished,  by  increasing  or  diminishing  the  force  of  the  per- 


24:  •  PHYSICAL  DIAGNOSIS. 

cussion  blow.  But  in  puhnonarij  percussion,  you  will  find  that 
the  intensity  depends  not  only  on  the  force  of  the  blow,  but 
is  further  modified  by  the  amount  of  air  contained  in  the  lung 
tissue,  or  by  the  thickness  of  the  soft  parts  covering  the  tho- 
racic walls,  and  also  by  the  elasticity  of  the  costal  cartilages. 

The  Pitch  of  the  percussion  sound  is  always  low  over 
healthy  lung  substance,  and,  as  a  rule,  the  greater  the  quantity 
of  air  contained  in  the  corresponding  pulmonary  tissue,  the 
lower  the  pitch :  consequently,  you  will  find  the  pitch  of  the 
percussion  sound  varying  very  perceptibly  in  the  different  re- 
gions of  a  healthy  chest.  You  can  however  famiharize  the  ear 
with  the  characters  of  normal  pitch,  only  by  constant  practice. 

Quality  in  sound  is  that  element  by  which  we  distinguish 
any  given  sound  from  every  other.  Thus  it  is  by  the  quality 
that  you  know  the  sound  of  one  musical  instrument  from 
another.  The  quahty  of  the  note  emitted  on  percussion  over 
healthy  lung  substance,  and  termed  normal  vesicular  reso- 
nance, is  sufficiently  marked  and  peculiar  to  be  easily  recog- 
nized, though  it  cannot  be  easily  described,  and  is  to  be 
learned  only  by  experience. 

The  Duration  of  a  given  sound  you  will  find  varying 
according  to  the  pitch  of  that  sound  ;  the  higher  the  pitch,  the 
shorter  the  duration,  and  vice  versa.  For  example,  the  dura- 
tion of  the  percussion  sound  is  perce23tibly  longer  in  the  infra- 
clavicular region  of  a  healthy  chest  than  over  the  heai*t. 

Tou  will  find  that  a  certain  definable  relationship  exists  be- 
tween these  respective  elements  of  the  percussion  note,  which 
has  a  correspondence  to  the  different  regions  of  the  chest. 
Thus  after  noting  the  intensity,  pitch,  quality,  and  duration  of 
the  j)ercussion  sound  in  the  infra- clavicular  region,  you  will 
find  that  over  the  heart  it  has  a  higher  pitch  and  harder 
quality,  but  a  less  intensity  and  a  shorter  duration. 

The  substance  which  receives  the  stroke  in  mediate  per- 
cussion is  termed  a  lolessimeter,  of  which  many  varieties  have 


PERCUSSION.  2g 

been  devised,  made  of  wood,  ivory,  gutta  percha,  etc.  They 
are  in  nowise  superior,  however,  to  the  left  index  or  middle 
fingers,  when  their  palmar  surface  is  appHed  evenly  to  the 
chest,  for  these,  besides  being  of  course  the  most  lianthj,  also 
answer  best  the  chief  requisite  of  a  plessimeter  in  that  they 
can  be  easily  fitted  with  accuracy  to  any  part  of  the  thoracic 
walls.  Moreover,  their  own  proper  sound,  on  being  sti'uck,  is 
inappreciable,  which  is  not  the  case  with  ivory,  wood,  etc. 
Likewise,  you  will  discover  nothing  better  to  strike  ivitli  than 
the  finger  tips  of  the  other  hand,  brought  into  line ;  while  for 
gentle  percussion,  the  middle  finger  alone  may  suffice. 

Now,  as  the  practice  of  percussion  requires  some  manual 
dexterity,  and  the  correctness  of  its  indications  depends  in 
great  measure  upon  the  mode  in  which  it  is  performed,  you 
will  find  it  useful  to  have  recourse  to  the  following  rules  as 
your  gTudes  : 

First.  You  should  attend  as  carefully  to  the  position  of 
your  patient  as  a  photographer  would  if  he  were  going  to 
take  his  likeness.  Whether  lying,  sitting,  or  standing,  his 
body  should  rest  on  the  same  plane,  and  his  hmbs  be  dis- 
posed similarly,  on  either  side,  so  as  to  render  the  muscular 
tissue  covering  the  thoracic  walls  equally  tense.  In  percuss- 
ing particular  regions,  however,  the  first  aim  is  to  make  the 
intervening  tissue,  as  firm  and  thin  as  possible.  Thus  \\  hen 
you  percuss  the  front  of  his  chest,  the  arms  should  hang 
loosely  down,  but  the  head  be  thrown  back.  On  the  contrary, 
the  arms  should  be  raised  to  the  level  of  the  head  when  you 
are  percussing  the  lateral  regions,  and  should  be  crossed  in 
front,  the  patient  leaning  moderately  forwards  when  you  per- 
cuss the  back.  It  is  better  to  percuss  on  the  naked  skin  ;  but 
various  considerations  often  make  this  unadvisable,  when 
you  should  then  aim  to  have  the  covering  as  soft,  thin,  but 
especially  as  even  as  possible. 

Second.    The  two  sides  of  the  chest  should,  for  comparison, 


26  PHYSICAL  DIAGNOSIS. 

be  percussed  in  the  same  stages  of  the  respiratory  act.  You 
should  also  take  care  to  compare  only  corresponding  portions 
in  the  two  sides.  Thus  you  should  not  compare  a  note  during 
inspiration  on  the  right  side  with  one  during  expiration  on 
the  left,  nor  that  over  a  rib  with  that  of  an  interspace. 

TJiircL  The  finger  or  plessimeter  should  be  apphed  with 
equal  firmness,  and  in  the  same  parallel  to  both  sides  in  suc- 
cession, and  the  force  of  the  percussion  should  be  exactly  the 
same  ;  for  the  sound  will  vary  considerably  even  on  the  same 
spot,  whether  you  press  lightly  or  firmly  with  your  finger, 
whether  it  is  across  a  rib  or  along  it,  and  finally,  whether  you 
strike  gently  or  forcibly. 

Fourth.  The  stroke  in  percussion  should  be  made  from  the 
wrist  alone,  the  arm  and  forearm  not  participating  in  it ;  and 
its  force  should  be  proportioned  to  the  depth  of  the  part  to  be 
examined, — gentle  if  superficial,  and  forcible  when  deep  seated. 

Percussion  in  Health. — The  significance  of  the  percussion 
sounds  in  disease  depends  so  entirely  on  their  variation  from 
the  sounds  which  are  proper  to  the  part  in  health,  that  you 
cannot  pay  too  much  attention  to  the  various  characters  of 
normal  thoracic  percussion ;  for  on  this,  almost  every  deduction 
which  results  from  your  examination  is  based.  Now  the  per- 
cussion sounds  differ  materially  in  a  healthy  thorax  according 
to  the  region  percussed.  Taking  the  percussion  note  of  the 
infra-clavicular  region  as  the  standard  for  pulmonary  percus- 
sion, we  find  each  of  the  other  regions  has  its  own  variations 
fi'om  it.  In  the  right  infra-mammary  region  30U  wiU  get,  by 
gentle  percussion,  the  same  note  as  in  the  infra-clavicular ;  but 
forcible  percussion,  at  and  below  the  fourth  interspace,  will 
raise  the  pitch  and  harden  the  quality,  owing  to  the  presence 
of  the  liver  within  the  shelving  border  of  the  lung.  Over  the 
left  infra-mammary  region,  the  pitch  is  similarly  varied  from 
the  presence  of  the  heart,  until  it  reaches  complete  flatness  at 
its  inner  border.     The  resonance  of  the  rigid  itfra-mammary 


SCAPULAE  REGION.  27 

region  lias  a  harder  quality,  higher  pitch,  and  shorter  duration, 
from  the  presence  of  the  liver  immediately  beneath.  The  left 
infra-mammary  region  is  similarly  affected  at  its  inner  part 
by  the  left  lobe  of  the  liver,  and  at  its  outer  border  by  the 
spleen,  while  the  intermediate  space  gives  a  tympanitic  reso- 
nance from  the  subjacent  stomach.  Over  both  clavicles  you 
will  get  a  mixed  pulmonary  and  osseous  resonance,  while  in 
the  supra-sternal  region,  the  percussion  sound  has  a  distinctly 
tubular  charactei*.  In  the  superior  sternal  region,  it  has  a  bony 
tubular  resonance  down  to  the  second  rib ;  below  this,  to  the 
third  rib,  it  is  raised  in  pitch  and  hardened  in  quahty.  The 
dulness  on  percussion  becomes  complete  in  the  next  region,  or 
inferior  sternal,  owing  to  the  presence  of  the  heart  and  great 
vessels,  together  with  the  left  lobe  of  the  liver. 

The  Superior  and  Middle  Axillary  regions  are  extremely 
resonant  as  far  down  as  the  fourth  interspace  ;  the  pitch  is 
even  lower  than  in  the  infra-clavicular  region,  but  below  the 
fourth  interspace,  the  pitch  rises,  till  complete  dulness  is 
found  on  a  level  with,  and  below  the  seventh  rib.  Tliis  dul- 
ness continues  through  the  infra-axillary  regions  on  either 
side. 

In  the  Superior  Scapular  and  Scapular  regions  the  per- 
cussion sound  is  high-pitched  and  hard  in  quality,  except  in 
the  supra-spinous  fossae,  vfhere  it  has  the  soft  quahty,  charac- 
teristic of  pulmonary  percussion.  In  the  infra-scapular  region 
you  have  pulmonary  resonance  as  far  down  as  the  tenth  rib, 
and  complete  flatness  below.  In  the  inter-scapular  region,  the 
percussion  is  high-pitched  and  tubular  in  quality. 

Besides  variations  in  percussion  sounds  dependent  on  differ- 
ence in  regions,  there  are  stiU  others  ascribable  to  age,  sex, 
idiosyncrasies,  etc.  You  will  find  the  percussion  sound  in 
children  of  a  softer  quahty  and  lower  pitch  than  in  adults : 
while  in  the  aged  it  rises  in  pitch,  and  measurably  loses  its 
pulmonary  quality.     In  females,  the  percussion  sound  is  rela- 


28  PHYSICAL  DIAGNOSIS. 

tively  more  pulmonary  in  all  its  cliaracters  than  in  males. 
Marked  deformity  of  the  chest,  whether  congenital  or  acquii-ed, 
also  modifies  the  normal  resonance.  But  it  also  varies  mate- 
rially in  different  individuals  who  are  equally  healthy.  In 
some  persons  this  difference  may  be  accounted  for,  w^hile  in 
others  it  cannot ;  but  as  a  nde  the  thinner  the  chest  walls, 
the  greater  is  the  intensity,  the  lower  the  pitch,  and  the  more 
pulmonary  the  quahty  of  the  percussion  sound. 

Percussion  in  Disease. — It  is  obvious,  from  what  pre- 
cedes, that  whatever  modifies  the  density  of  the  lung  substance, 
and  changes  its  proper  elasticity,  wiU  cause  a  corresponding 
modification  in  the  normal  pulmonary  resonance ;  for  as  the 
lung  texture  is  rendered  more  dense,  or  less  so,  than  natural, 
the  percussion  sound  passes  through  every  gradation  from 
marked  resonance  to  complete  duhiess.  These  modifications, 
caused  by  disease,  we  would  classify  under  the  following 
heads ;  viz..  Exaggerated  Pulmonary  Resonance,  Dulness,  Flat- 
ness, Tympanitic  Resonance,  Vesiculo- Tympanitic  Resonance, 
Amijlioric  Resonance,  and  Craclced-Pot  Resonance. 

Exaggerated  Pulmonary  Resonance  consists  in  an  in- 
crease of  the  intensity  of  the  sound ;  the  pitch  being  slightly 
lower,  while  the  quahty  remains  unchanged.  This  sign  may 
exist  to  a  shght  degi'ee  over  the  whole,  or  over  a  portion  of  a 
lung  which  is  performing  more  than  its  usual  share  of  labor. 
Thus  if  one  pleural  cavity  is  fiUed  with  fluid,  or  if  one  lung  is 
solidified  by  the  exudation  of  pneumonia,  or  the  seat  of  exten- 
sive tuberculous  deposit,  you  will  find  the  resonance  of  per- 
cussion increased  on  the  opposite  una£fected  side,  which  is 
now  doing  double  duty.  Extensive  anasmia,  by  lessening  the 
quantity  of  blood  in  the  lungs,  may  also  give  rise  to  shght 
extra  resonance  on  percussion. 

Dulness. — This  consists  iu  a  diminution  of  the  pulmonary 
resonance,  and  may  be  shght,  considerable,  or  complete, 
according  as  more  or  less  air  enters  the  affected  part.     In 


RESONANCE  29 

dulness,  the  intensity  is  climinishecl,  tlie  pitch  raised,  the 
duration  shortened,  and  the  quahtj  hardened.  Didness 
always  indicates  a  decrease  in  the  normal  proportion  of  air  in 
the  part,  and  is  an  important  physical  sign  in  a  number  of  dis- 
eases, as  in  pneumonia,  tuberculosis,  oedema  of  the  lungs,  etc. 

Flatness. — This  indicates  the  total  absence  of  air,  so  that 
there  is  no  proper  pulmonary  resonance,  and  its  sound  re- 
sembles that  produced  by  percussing  the  thigh.  We  have 
examples  of  this  when  we  percuss  over  fluid  contained  in  the 
pleural  or  pericardial  serous  cavities,  or  when  tumors  are 
developed  in  the  thorax,  etc. 

Tympanitic  Resonance. — This  is  marked  by  the  absence 
of  proper  pulmonaiy  quality  in  the  characters  of  its  resonance; 
the  type  being  the  resonance  of  a  tympanitic  abdomen  on  per- 
cussion ;  in  intensity  it  exceeds  normal  pulmonary  percus- 
sion, and  is  higher  in  pitch.  As  a  physical  sign  in  tho- 
racic affections  it  usually  indicates  the  presence  of  air  in  the 
pleural  cavity,  as  in  pneumo-thorax.  In  this  affection  we 
have  au'  contained,  not  in  small  vesicles,  but  in  a  large  free 
space,  and  hence  we  have  not  the  vesicular,  but  the  tympan- 
itic quality  in  the  sound. 

Vesiculo- Tympanitic  Resonance. — ^By  this  term  (intro- 
duced by  Prof.  A.  Flint),  it  is  meant  to  denote  a  resonance  in 
which  we  have  both  the  tympanitic  and  vesicular  qualities. 
It  is  higher  pitched,  but  more  intense  than  normal  pulmonary 
resonance,  and  is  present,  when  the  increase  of  the  volume  of 
the  lung,  as  in  some  cases  of  emphysema,  is  so  great  as  to 
dilate  and  render  extremely  tense  the  thoracic  walls. 

Amphoric  Resonance,  unhke  tympanitic  resonance  (which 
gives  an  impression  of  fulness),  is  suggestive  of  shallowness 
or  emptiness ;  it  resembles  the  sound  produced  by  flapping 
the  cheek  when  the  mouth  is  closed,  and  fully  but  not  forcibly 
inflated.  It  is  most  frequently  heard  over  a  large  superficial 
cavity,  having  thin,  tense  walls,  and  hence  is  usually  indica- 


30  PHYSICAL  DIAGNOSIS. 

tive  of  phtliisis.     In  case  of  pleuro-pneumonia,  a  sound  more 
or  less  amphoric  in  character  is  sometimes  heard. 

Cracked-Pot  Resonance  is  usually,  though  not  invariably, 
heai'd  in  connection  with  amphoric  resonance.  It  resembles 
the  sound  produced  by  striking  the  hands,  loosely  folded 
across  each  other,  against  the  knee,  the  contained  air  being 
suddenly  forced  out  between  the  fingers.  If  there  exists  a 
pulmonary  cavity  of  large  size,  with  thin  walls,  communicating 
freely  with  a  large  bronchial  tube,  the  chest  walls  being  at  the 
same  time  particularly  yielding,  forcible  percussion,  with  the 
patient's  mouth  open,  wiU  yield  cracked-pot  resonance.  Dr. ' 
Hughes  Bennett  states  that  a  cracked-pot  resonance  may  be 
elicited  in  various  diseases  of  the  chest,  and  even  when  the 
chest  is  perfectly  sound.  I  have  never  obtained  true  cracked- 
pot  resonance  unless  over  a  pulmonic  cavity,  or  in  pneumo- 
thorax. 

Auscultatory  Percussion. — This  is  a  combination  of  aus- 
cultation and  percussion.  It  was  first  brought  to  the  notice 
of  the  profession  by  Drs.  Camman  and  Clark  in  1840. 

Their  method  of  performing  it  was  as  follows :  Press  the 
objective  end  of  a  stethoscope,  constructed  expressely  for  this 
purpose*  (while  the  ear-piece  is  accurately  fitted  to  the  ear), 
firmly  and  evenly  on  the  surface,  directly  over  that  portion  of 
the  organ  or  tumor  to  be  examined  whicTi  is  most  superficial ; 
then  let  percussion  be  performed  in  the  usual  way,  one  or  two 

*  This  instrument  is  a  solid  cylinder  of  wood,  shaped  in  the  direction  of  the 
woody  fibres,  six  inches  in  length,  and  ten  or  twelve  lines  in  diameter ;  fur- 
nished with  an  ear-piece  which  will  allow  nearly  the  whole  cylinder  to  pass 
through  it,  so  that  it  may  apply  directly  to  the  tube  of  the  ear,  without  change 
of  medium.  To  avoid  as  much  as  possible  the  sound  of  the  thoracic  walls,  as 
is  desirable  in  some  cases,  this  instrument  has  been  modified,  by  reducing  it  at 
its  objective  extremity  to  a  truncated  wedge,  leaving  the  other  extremity  as 
before.  This  is  applied  between  the  ribs  so  as  not  to  touch  them,  and  at  the 
same  time  approach  somewhat  nearer  the  object  under  examination. — N.  T. 
Jottr.  of  Med.  &  Surg.,  July,  1840. 


AUSCULTATORY  PERCUSSION.  3j 

inclies  from  tlie  point  at  wliicli  the  stethoscope  is  applied. 
The  percussion  sound  communicated  to  the  ear  in  this  manner 
fcir  exceeds  in  intensity  and  distinctness  the  same  sound  when 
communicated  through  the  medium  of  the  air.  The  shghtest 
change  in  pitch  and  quaHfcy  is  also  readily  appreciated. 

The  benefits  claimed  for  auscultatory  percussion  by  its  orioi- 
nators  are  :  "  First,  That  the  heart  can  be  measured  in  all  but 
its  antero-posterior  diameters,  under  most,  perhaps  all  cu'cum- 
stances  of  health  and  disease,  with  hardly  less  exactness  than 
we  should  be  able  to  do  if  the  organ  were  exposed  before  us. 

"  Second,  That  the  outlines  of  the  hver  can  be  traced  with 
much  greater  certainty  than  by  ordinary  percussion,  in  cu- 
cumstances  of  health ;  and  to  circumscribe  it  in  many  condi- 
tions of  disease  in  which  ordinary  percussion  is  not  appH- 
cable. 

"  TJiird,  That  the  dimensions  of  the  spleen  can  be  ascer- 
tained in  circumstances  that  baffle  ordinary  j)ercussion. 

"  Fourth,  That  by  it  we  can  mark  the  superior,  inferior,  and 
external  hmits  of  the  kidneys.  Ascites  presents  no  obstacle 
to  the  measurement  of  these  organs :  and  from  enlarged 
spleen  the  left  kidney  is  easily  distinguished." 


LESSON    IV. 

jiuscultation. 

Auscultation  is  a  kind  of  eavesdropping,  for  in  it  you  bend 
your  ear  to  catcli  the  significance  of  sounds  that  come  from 
hidden  quarters,  which  no  one  may  open.  As  in  percussion, 
so  here,  auscultation  may  be  immediate,  when  the  ear  is  ap- 
plied directly  to  the  bared  or  thinly  covered  surface  ;  and 
mediate  when  the  sounds  are  conducted  from  the  surface  to 
the  ear  through  a  tubular  instrument  called  a  stethoscope. 

Both  of  these  methods  have  their  exclusive  advocates,  but 
as  each  has  its  own  advantages,  I  would  strongly  recommend 
your  becoming  equally  practised  in  the  use  of  them  both. 
Per  se,  immediate  auscultation  answers  best  for  pulmonary  ex- 
aminations ;  but  in  examining  the  heart,  where,  as  in  valvular 
murmurs,  you  have  to  analyze  circumscribed  sounds,  your  ear 
will  often  be  confused  by  the  noise  of  its  near  neighbor,  the 
left  lung,  or  by  other  cardiac  sounds  than  the  one  imder  ex- 
amination, and  you  will  find  the  stethoscope  then  assists  you 
by  its  measurably  excluding  the  sounds  which  have  their  seat 
outside  the  rim  of  the  chest-piece.  Besides,  there  are  cases 
where  the  state  of  the  surface  may  make  you  very  reluctant 
to  bring  your  ear  into  immediate  contact  with  the  patient's 
person,  while  in  other  cases  you  may  not  be  allowed  to  do  so, 
and  in  such  of  course,  you  would  have  recourse  to  the  stetho- 
scope. 

Stethoscopes  of  great  variety  as  to  form  and  material  have 
been  recommended,  each  inventor  claiming  some  superiority 


AUSCULTATION.  gg 

in  principle  or  shape  for  his  own  instrument.  They  may  all, 
however,  be  referred  to  two  general  classes  ;  viz.,  flexible  and 
solid.  I  regard  as  the  best  representatives  of  these  two  classes 
those  devised  by  the  late  Dr.  Camman  of  this  city.  For  gen- 
eral use  I  would  recommend  his  Binaural  Stethoscope,  which 
has  connected  with  the  cup  that  is  apphed  to  the  surface,  two 
tubes  that  fit  into  each  ear.  It  requires  some  practice  to 
become  adepts  in  its  use ;  but  once  accustomed  to  it,  you  will, 
I  think,  find  no  other  stethoscope  superior  to  it,  for  it  closes 
both  ears  to  every  other  but  the  desired  sounds. 

In  the  performance  of  auscultation,  as  of  percussion,  certaia 
precautions  are  requisite  in  order  to  insure  accurate  results. 
The  following  rules  will  be  found  of  service  : 

First.  The  chest  should  in  immediate  but  not  ia  mediate 
auscultation,  have  some  thin,  soft  covering,  which  will  not  in- 
terfere with  the  transmission  of  sound,  or  itself  produce  any 
from  the  respiratory  movements  of  the  thoracic  walls  to  wliich 
it  is  applied.  A  soft  towel  smoothly  spread  over  the  surface 
answers  this  purpose  very  well. 

Second.  The  position  of  the  patient  should  be  regulated  in 
the  same  manner  as  for  the  performance  of  inspection,  care 
being  taken  that  the  parts  should  be  in  a  state  of  perfect 
repose.  The  position  of  the  examiner  should  be  as  unre- 
strained as  possible,  and  he  should  by  all  means  learn  to  con- 
centrate his  attention  on  the  sounds  which  reach  his  ear. 

Third.  The  ear,  or  the  stethoscope,  should  be  applied  firmly, 
but  not  forcibly,  to  the  surface,  and  when  the  stethoscope  is 
used,  it  is  important  that  its  rim  press  equally  and  evenly  on 
the  part. 

Fourth.  As  in  percussion,  corresponding  parts  of  the  two 
sides  of  the  chest  should  be  compared  together,  nor  should 
the  examination  be  considered  complete  unless  it  has  included 
the  entire  chest.  In  acute,  thoracic  affections,  auscultation 
should  be  frequently  repeated. 


34  PHYSICAL-DIAGNOSIS. 

Fiftli.  The  examination  sliould  be  commenced,  if  possible, 
during  ordinary  respiration.  The  patient  should  then  be 
directed  to  take  a  full  inspiration,  then  to  cough,  and  then 
again  to  breathe  naturally.  The  latter  is  to  some  very  difficult 
when  under  examination,  and  they  sometimes  seem  equally 
incapable  of  comjjleting  a  full  imipiration.  In  such  instances 
our  object  may  be  attained  by  performing  the  act  ourselves, 
and  requesting  the  patient  to  imitate  it,  or  by  directing  him 
to  sigh.  If  these  expedients  fail,  direct  him  to  cough  contin- 
uously for  some  moments,  whereupon  a  full,  clear  insj^iration 
follows,  and  he  does  iavoluntarily  what  his  previous  efforts' 
have  failed  to  accomplish. 

Let  us  now  consider  the  important  subject  of  the  nature 
and  causes  of  the  respiratory  sounds  in  health. 

If  the  ear  be  apphed  to  a  healthy  chest  during  a  respiratory 
act,  a  soft,  breezy  murmur  will  be  heard,  composed  of  two 
periods ;  one  corresponding  to  the  movements  of  inspiration, 
and  the  other,  both  fainter  and  shorter,  to  that  of  expiration, 
and  which  are  termed  respectively  the  inspiratory  and  the 
expiratory  sounds  of  respiration.  The  elements  of  these 
sounds  are  analogous  to  those  of  percussion,  and  hence  we 
express  them  by  the  terms  Intensity,  Pitch,  Quality,  and  Dura- 
tion, to  which,  however,  we  now  add  a  fifth.  Rhythm,  which 
refers  to  the  relative  succession  of  the  two  periods  in  the  res- 
piratory act.  As  might  be  expected,  we  find  definite  propor- 
tionate variations  among  these  elements,  normally  present  in 
the  various  portions  of  the  respiratory  tract,  and  these  consti- 
tute distinct  varieties  of  respiratory  sounds,  which  are  named 
after  those  regions  in  which  they  occur  in  health.  Thus  we 
speak  of  vesicular,  bronchial,  tracheal,  and  laryngeal  respi- 
ration, each  of  these  sounds  having  its  own  proper  intensity, 
quality,  pitch,  etc.  The  left  infra-clavicular  region  in  a 
healthy  chest  furnishes  the  purest  vesicular  respiration  ;  the 
inter-scapular  region,  the  best  normal  broncliial  respu'ation ; 


AUSCULTATION.  gc 

and  by  placing  the  stethoscope  or  ear  over  the  larynx  and 
trachea,  you  will  hear  the  tracheal  and  larnygeal  breathin^^. 
These  integral  elements,  i.  e.,  pitch,  quahty,  duration,  etc.,  are 
due  to  differences  in  the  volume  and  velocity  of  the  current  of 
air  on  the  one  hand,  and  on  the  other  to  the  nature  of  the 
obstructions  which  it  meets  in  its  entrance  or  exit  through  the 
pulmonary  passages.  Every  complete  respiratory  sound,  how- 
ever, whatever  its  component  characters,  yet  retains  its  divi- 
sion into  inspiratory  and  expiratory  murmurs. 

Of  all  the  normal  respiratory  sounds,  that  which  stands  first 
in  importance  is  the  Vesicular.  The  best  representative  type 
of  the  normal  vesicular  murmur  is  found  in  the  left  infra-clavi- 
cular space,  where  you  will  hear  during  inspiration  a  sound 
of  a  gentle  rustling  character,  most  marked  at  the  end  of  the 
act.  The  intensity  and  duration  of  this  murmur  vary  in 
healthy  persons,  and  form  the  least  important  of  its  elements. 
Its  pitch,  however,  should  be  low.  The  expiratory  sound  when 
present  (it  being  absent  in  four  out  of  five  healthy  persons  when 
their  attention  is  not  directed  to  their  respiration)  is  much 
shorter  than  the  inspiration,  its  relative  duration  varpng  in 
different  individuals ;  its  intensity  is  less  than  in  inspiration, 
its  pitch  lower,  and  its  quality  harder ;  the  breezy  or  vesicular 
character  of  the  inspiratory  sound  being  wanting.  These  two 
sounds  follow  each  other  so  closely  that  they  may  be  said  to 
be  continuous,  and  this  fact  is  itself  an  important  element  of 
normal  vesicular  respiration.  It  should  be  noted  here,  how- 
ever, that  the  normal  respiratory  sounds  do  not  exactly  cor- 
respond in  the  two  infra-clavicular  regions.  On  the  right 
side  the  pitch  of  the  inspiratory  soimd  is  higher  than  on  the 
left,  and  less  breezy  in  quality ;  while  the  expiration  is  more 
pronounced  and  prolonged  in  duration.  This  disparity  should 
be  taken  into  account  in  all  doxiUM  cases,  such  as  in  sus- 
pected small  deposits  of  tubercle.  Age  also  affects  the  char- 
acters of  normal  vesicular  respiration  in   a  well-determmed 


36  PHYSICAL  DIAGNOSIS. 

and  peculiar  degree,  taking  for  the  standard  in  comparison 
the  above-mentioned  characters  of  respiration  -with  healthy 
middle-aged  individaals.  In  infancy,  the  intensity  of  both  the 
insphatory  and  expiratory  sounds  is  increased,  while  the  other 
elements  remain  the  same.  In  old  age,  on  the  other  hand,  the 
intensity  is  diminished,  the  duration  ui  inspiration  shortened, 
and  the  expiration  prolonged.  Sex  likewise  modifies  the  res- 
piratory sounds.  As  a  inile,  both  iuspii-atory  and  expiratory 
sounds  have  greater  intensity,  and  the  latter  is  oftener  present 
in  the  left  infra-clavicular  space,  in  the  female  than  in  the 
male.  In  females  the  inspiratory  sound  has  more  intensity  in 
the  upper  part  of  the  chest,  while  in  males  it  is  more  intense 
in  the  lower  and  posterior  portions.  If  the  ear  or  stethoscope 
be  applied  over  the  larynx  or  trachea,  a  sound  will  be  heard 
with  inspiration  and  expiration,  which  sound  is  termed  normal 
laryngeal  and  fracJieal  respiration.  From  vesicular  respu'ation 
it  differs  in  the  following  respects  :  in  quality  it  is  wholly 
tubular  ;  the  inspiratory  sound  is  more  intense  and  higher  in 
ipitcli ;  it  ends  a  little  before  the  inspiratory  act  is  completed, 
so  that  a  slight  interval  occurs  between  the  inspu'atory  and 
the  expiratory  sounds.  On  the  other  hand,  the  expiratory 
sound  is  tubular  in  quahty,  higher  in  pitch,  and  as  long,  or 
longer,  than  the  inspiratory. 

The  characters  of  the  next  variety  or  bronchial  respiration 
are  very  important  to  the  auscultator  from  their  common 
occurrence  and  significance  in  disease.  They  are  those  of 
tracheal  respiration,  only  in  a  less  marked  degree,  being  less 
tubular  in  quahty,  while  the  interval  between  the  inspiratory 
and  expiratory  sound  is  shorter. 

Now,  the  more  thoroughly  youleam  these  varieties  in  healthy 
resphation,  the  better  you  will  be  prepared  to  understand 
what  respiratory  sounds  are  abnormal.  Very  often  you  will 
hear  in  disease,  what  you  recognize  as  one  of  the  normal 
sounds,  but  you  know  that  this  famiUar  sound  has  in  this  case 


ALTERATIONS  IN  INTENSITY.  gy 

a  serious  import,  because  it  is  not  tlie  natural  sound  of  tliat 
locality.  But  you  may  also  hear  sounds  whose  character 
differs  from  any  normal  type.  "We  may,  however,  say  in  gen- 
eral that  abnormal  sounds  consist  in  changes  from  the  stand- 
ard of  healthy  respiration  as  regards  the  three  elements  of 
intensity y  rhythm,  and  quality,  thus : 


In  Intensity  the  respiratory 
miirmur  may  be    .    .    . 


In  Rhythm  the  respiratory 
murmur  may  be    .     .    . 


In  Quality  the  respiratory 
murmur  may  be    .    .    . 


1 1st.  Exaggerated  or  increased. 
2n(i.  Diminished  or  feeble. 
[Srd.  Absent  or  suppressed. 

'1st.  Interrupted. 
2nd.  The  interval  between  inspiration 

and  expiration  be  prolonged. 
3rd.  Expiration  be  prolonged. 

1st.  Eude,        termed  rude  respiration. 
2nd.  Bronchial     "       bronchial     " 
3rd.  Cavernous,    "       cavernous    " 
4th.  Amphoric,    "       amphoric    " 


Alterations  in  Intensity. 

Exaggerated  Respiration  differs  from  the  normal  vesicular 
respiration  only  in  an  increase  in  the  intensity  and  duration  of 
the  respiratory  sounds.  It  is  sometimes  called  puerile  respi- 
ration, from  its  resemblance  to  the  respiration  of  children, 
and  is  present  in  a  part  where  respiration  is  more  active  than 
usual,  owing  to  deficient  action  elsewhere,  as  in  the  upper 
part  of  one  lung  whose  lower  lobe  is  consolidated  by  pneu- 
monia, or  similarly  where  one  lung  does  the  duty  of  its  feUow 
which  is  solidified  by  the  pressure  of  a  pleuritic  efiusion. 

Diminished  or  Feeble  Respiration  differs  from  normal 
vesicular  respiration  only  in  a  diminution  in  the  intensity  and 
duration  of  the  respiratory  sounds.  It  may  arise  from  any 
cause  which  interferes  directly  or  indirectly  with  the  expan- 
sion of  the  lung,  or  which  diminishes  the  elasticity  of  its 
tissue.     Of  the  first  condition  we  have  illustrations  in  affec- 


38  PHYSICAL  DIAGNOSIS. 

tions  whicli  restrain  the  movements  of  the  thoracic  walls,  as 
pleuritic  pain,  rheumatism,  paralysis,  etc. ;  or  when  there  is 
some  obstruction  to  the  entrance  of  air  into  the  lungs,  such  as 
in  diseases  of  the  larynx,  trachea,  or  bronchial  tubes,  or 
again  when  a  pleuritic  effusion  or  a  tumor  presses  the  lungs 
back  from  the  chest  walls,  though  not  to  a  degree  sufficient  to 
prevent  aU  air  from  entering  them.  Of  the  second  condition 
we  have  examples  in  pulmonary  emphysema,  and  in  incipient 
tubercular  deposits. 

Absent  or  Suppressed  Respiration  occurs  whenever,  from 
some  cause,  the  play  of  the  lung  is  suspended ;  and  this  may 
be  either  from  external  pressure,  as  when  the  lung  is  forced 
against  the  spinal  column  by  the  presence  of  fluid  or  air  in 
the  pleural  cavity ;  or,  on  the  other  hand,  when  a  complete 
obstruction  of  the  main  bronchi  prevents  the  air  from  either 
entering  or  leaving  the  lungs. 

Alterations  in  MJiythni, 

Interrupted  Respiration. — In  health  the  respiratory  and 
expiratory  sounds  are  even  and  continuous,  with  a  brief 
interval  between  each  respiratory  act ;  but  this  may  be  altered 
in  disease,  and  both  sounds,  especially  the  inspiratory,  may 
have  an  interrupted  or  jerking  character,  termed  by  some 
"cog-wheel  respiration."  We  have  examples  of  this  kind  of 
respiration  in  asthma,  pleurodynia,  first  stage  of  pleurisy,  and 
incipient  phthisis.  It  is  most  frequently  associated  with 
tubercle,  and  may  be  due  probably  to  some  gelatinous  mucus 
adhering  to  the  walls  of  the  finer  bronchial  tubes,  which, 
though  not  sufficient  to  produce  rale,  still  obstructs  the  free 
ingress  and  egress  of  the  air. 

Prolonged  Interval  between  Inspiration  and  Expira- 
tion.— Instead  of  these  two  sounds  closely  succeeding  one 
another,  they  may  be  separated  by  a  distinct  interval.  "WTien 
this  occurs,  either  the  inspiratory  sound  is  shortened,  or  the 


ALTERATIONS  IN  QUALITY.  39 

expiratory  sound  is  delayed  in  its  commencement.  In  the 
first  instance  it  is  the  result  of  pulmonary  consolidation,  as  in 
tubercle ;  in  the  second,  the  elasticity  of  the  pulmonary  tissue 
is  impaired,  as  in  emphysema,  no  sound  being  heard  during 
the  first  portion  of  the  expiratory  act. 

Prolonged  Expiration. — Here  the  ratio  between  normal 
inspiration  and  expiration  is  inverted.  The  expiration  at 
times  is  twice  or  three  times  as  long  as  the  inspiration. 

It  is  always  due  to  a  want  of  freedom  in  the  egress  of  air 
from  the  lungs.  The  most  common,  and  therefore,  practically 
speaking,  the  most  important  cause  of  prolonged  expiration 
is  tubercular  deposit  in  the  lung.  Excessively  prolonged  ex- 
piration is  to  be  met  with  in  vesicular  emphysema,  and  this  is 
to  be  distinguished  from  the  prolonged  expiration  of  phthisis 
by  its  pitch,  which  in  emphysema  is  loio,  lower  than  the  inspi- 
ration, while  in  phthisis  it  is  high,  higher  than  the  inspiration, 
and  tubular  in  quality. 

Alterations  in  Quality. 

Rude  Respiration. — This  is  termed  (by  Prof.  A.  Flint) 
broncho-vesicular  respiration.  In  this  variety  both  inspi_ 
ratory  and  expiratory  sounds  lose  their  natural  softness ;  the 
breezy  or  vesicular  quahty  is  lost;  the  sounds  are  higher 
pitched  and  more  tubular  in  character,  while  the  expiration 
has  more  intensity,  higher  pitch,  and  longer  duration  than 
the  inspiration.  Eude  respiration  always  indicates  more  or 
less  consolidation  of  lung  tissue.  In  normal  vesicular  respi- 
ration, the  sounds  produced  by  the  vibrations  of  the  air  in 
tli3  air  cells  and  finer  bronchi  obscure  chat  produced  in  the 
trachea  and  larger  bronchial  tubes  (healthy  lung  substance 
being  a  poor  conductor  of  sound)  ;  but  so  soon  as  any  portion 
of  lung  becomes  consolidated,  the  vesicular  element  of  the 
respiratory  sound  is  diminished  and  the  bronchial  element 


40  PHYSICAL  DIAGNOSIS. 

becomes  prominent ;  this  change  constitutes  rude  respira- 
tion. It  embraces  everj  degree  of  modification  between 
complete  bronchial  respiration  on  the  one  hand,  and  normal 
yesicular  breathing  on  the  other  ;  the  increase  in  bronchial 
characters  corresponding  with  the  degree  of  consoHdation. 
Rude  respiration  is  of  practical  value,  principally  in  the  diag- 
nosis of  incipient  phthisis. 

Bronchial  Respiration  is  characterized  by  an  entire  ab- 
sence of  ail  vesicular  quality.  The  inspiratory  sound  is  high 
pitched  and  tubular  in  character ;  the  two  sounds  are  sepa- 
rated by  a  brief  interval ;  the  expiratory  is  still  higher  pitched 
and  more  intense  than  the  inspiratory,  is  as  long  or  longer, 
and  of  the  same  tubular  quality.  "WTienever  this  modification 
of  the  respiratory  sound  is  present,  where  in  health  normal 
vesicular  murmur  should  be  heard,  consolidation  of  lung 
substance  may  be  inferred.  Consequently  it  is  an  important 
diagnostic  sign  in  many  pulmonary  affections^  such  as  pneu- 
monia, phthisis  pulmonalis,  pulmonary  apoplexy,  etc. 

Cavernous  Respiration. — In  some  respects  this  resembles 
bronchial  respiration,  and  it  is  often  difficult  to  distinguish 
one  from  the  other.  Some  distinguished  auscultators  declare 
that  this  sign  does  not  exist. 

Its  distinguishing  characteristics  are,  on  inspiration,  a  soft, 
blo^vdng,  low-pitched  sound,  non-vesicular  in  character :  as  a 
rule,  the  expiratory  sound  is  lower  pitched  than  the  inspira- 
tory, and  is  always  prolonged  and  puffing. 

For  its  production,  there  must  be  a  cavity  of  considerable 
size  in  the  lung  substance,  having  free  communication  with 
a  bronchial  tube.  The  cavity  must  be  empty  and  near  the 
surface,  its  walls  must  be  sufficiently  flaccid  to  expand  with 
inspiration,  and  collapse  with  expiration.  This  sign  is  most 
frequently  met  with  in  the  third  stage  of  phthisis. 

Amphoric  Respiration.— Whenever  the  respiratory  sound 
has  a  musical  intonation  or  metallic  quality,  resembling  that 


ALTERATIONS  IN  QUALITY.  ^ 

produced  by  blowing  gently  into   the   moutli  of  an  empty 
bottle,  it  is  called  amj)lioric. 

Tlie  ampboric  character  accompanies  both  acts  of  respira- 
tion, especially  the  expiratory. 

It  may  be  due  to  tubercular  or  other  excavations  in  the 
lung  substance,  or  to  an  opening  from  the  bronchial  tube  into 
the  pleural  cavity,  giving  rise  to  pneumo-thorax.  In  both 
cases  the  sound  is  produced  by  vibrations  of  air  in  a  cavity, 
which  are  excited  by  a  current  of  air  from  a  bronchial  tube. 
The  cavity  in  the  lung  substance  which  gives  rise  to  amphoric 
respiration  must  be  of  large  size,  empty,  with  tense,  firm 
walls,  so  as  not  to  collapse  with  expiration,  and  it  must  com- 
municate freely  with  a  large  bronchial  tube. 

This  sign  is  mainly  of  importance  in  the  diagnosis  of  ad- 
vanced phthisis  and  pneumo-thorax. 

This  completes  the  history  of  the  most  important  altera- 
tions in  the  natural  respiratory  sounds  produced  by  disease. 
With  few  exceptions  they  are  no  new  sounds,  but  are  heard  in 
the  healthy  chest,  and  become  significant  of  disease  only 
when  heard  ia  unnatural  locations. 


LESSON  V. 

Abnormal  or  jidventitious  Sounds* 

The  sounds  which  are  now  to  be  considered  are  termed 
Adventitious,  because  thej  are  not  heard  in  health,  but  are- 
found  in  disease,  either  accompanying  the  normal  respiratory 
sounds,  or  wholly  supplanting  them.  They  vary  much  in  their 
character  according  to  their  origin ;  that  is,  whether  they  are 
caused  by  changes  in  the  texture  of  the  lung  itself,  or  in  its 
investments ;  and  hence,  in  order  to  appreciate  their  signifi- 
cance when  present,  you  should  know  well  beforehand  their 
seat  and  mode  of  production. 

These  sounds  which  origiaate  in  the  air  passages,  or  in  cav- 
ities abnormally  communicating  with  them,  are  called  rcHes,  or 
rhoncM.  Of  the  two,  I  prefer,  and  shall  use,  the  term  rale,  and 
would  classify  the  varieties  of  rales  which  meet  us  in  practice, 
as  foUows : 


Bales. 


Dry  rales. 


Sonorous  rales. 
Sibilant  rales. 


f  Mucous  rales  (large  and  small). 
Moist  rales.   \  Sub-crepitant  rales. 
{,  Crepitant  rales. 

j  Gurgles  (large  and  small). 
(  Mucous  click. 


A  rale  may  originate  in  the  trachea,  in  the  bronchi,  large  or 
small,  m  the  air  cells,  or  in  abnormal  cavities  situated  either 
witlmi  or  without  the  lung  substance.  It  may  be  produced 
within  the  air  tubes,  either  by  a  diminution  of  their  cahbre, 


RALES. 


43 


by  the  vibrations  of  viscid  matter  collected  in  them,  or  by  the 
air  bubbling  through  fluid  present  ra  the  bronchi  and  in  the 
air  vesicles,  or  in  larger  or  smaller  cavities.  A  rale  may  be 
either  dry  or  moist  in  its  character,  and  may  be  audible  either 
in  iuspiration  or  in  expiration,  or  in  both. 

Fig.  3. 


Sonorous  aiid  Sibilant  iJaJes.— Dacosta. 

Dry  Rales  are  divided  into  sonorous  and  sibilant,  according 
to  the  pitch  and  quahty  of  the  sound  ;  if  a  rale  is  low  pitched 
and  snoring  in  character,  it  is  termed  sonorous  ;  if  high 
pitched  and  whistling,  it  is  termed  sibilant. 

The  Sibilant  rale  may  be  heard  during  both  inspiration  and 
expiration.    It  recurs  irregularly,  and  sometimes  is  so  high 


44  PHYSICAL  DIAGNOSIS. 

pitched  as  to  become  hissing  in  its  character.  Its  seat  is  the 
smaller  bronchi,  and  it  is  caused  either  by  the  narrowing  of 
these  tubes  from  thickening  of  the  mucous  tissues  lining  them, 
or  from  the  spasmodic  contraction  of  their  muscular  coat ;  or 
it  may  be  owing  to  the  yibrations  of  viscid  mucus  adhering  to 
their  walls.  In  most  instances  it  may  be  temporarily  removed 
by  violent  coughing. 

The  Sonorous  rale  may  also  be  heard  during  both  inspira- 
tion and  expiration.    As  above  mentioned,  it  is  a  low  pitched, 

Kg.  4. 


SuB-CREPimnT 


Cbkpitaot 


Crepitant  and  Sul-crepitant  Rales. — Daoosta. 

snoring  sound,  which  varies,  however,  in  intensity  from  a  slight 
rale  to  one  loud  enough  to  be  audible  at  a  distance  from  the 
chest.  It  has  for  its  seat  the  larger  bronchial  tubes,  and  is 
produced  by  conditions  of  those  tubes  similar  to  those  which 
cause  sibilant  rales  in  the  smaller  bronchi  ;  namely,  lessened 
cahbre  from  tumefaction  of  the  mucous  tissues,  or  from  spas- 
modic contraction,  or  from  pressure  on  the  tube  from  without, 
by  a  tumor,  an  exudation,  or  a  deposit ;  or  it  may  be  owing 
to  the  vibrations  of  a  thickened  fold  of  the  lining  membrane, 


RALES.  ^g 

or  of  viscid  mucus  adhering  to  it.  TLis  rale  is  specially  fre- 
quent in  bronchitis  and  spasmodic  asthma,  though  it  may  be 
present  in  almost  every  pulmonary  disease. 

Moist  Rales. — Under  this  head  may  be  included  the  crepi- 
tant, suh-crepitant,  and  mucous  rales. 

The  Crepitant  rale  is  composed  of  a  number  of  quick, 
minute,  and  sharp  sounds  of  a  crackhng  nature.  They  also 
persist  for  some  time  in  the  spot  where  they  are  first  heard ; 
they  are  audible  only  during  inspiration,  and  do  not  vary  in 
then'  character.  This  rale  undoubtedly  has  its  seat  in  the  air 
cells  and  interlobular  spaces.  There  are  two  views  as  to  its 
mode  of  production :  one,  that  it  is  the  result  of  air  bubbhng 
tlirough  fluid  in  the  vesicles  and  interlobular  spaces ;  the 
other,  that  at  the  end  of  each  expiration  a  viscid  secretion 
glues  together  the  walls  of  the  air  cells,  the  separation  of 
which  on  inspiration  gives  rise  to  the  craclding  sound.  It 
may  probably  be  produced  in  both  these  ways.  This  rale  is 
the  characteristic  sign  of  pneumonia,  though  it  is  not  infre- 
quent in  some  forms  of  pulmonary  congestion,  and  in  oedema 
of  the  lungs. 

The  Suh-crepitant  rale  is  a  moist,  bronchial  sound,  caused 
by  the  breaking  of  minute  air  bubbles  of  equal  size  and 
comparatively  few  in  number.  Its  seat  is  the  smallest  bronchi, 
and  the  liquid  through  which  the  air  passes  may  be  mucus, 
serum,  pus,  or  blood.  It  differs  from  the  crepitant  rale  in 
the  larger  size  of  the  bubbles,  and  is  heard  in  expiration  as 
well  as  in  inspiration.  This  rale  is  present  in  a  number  of 
affections.  "When  heard  on  both  sides  of  the  chest  posteriorly, 
it  indicates  capillary  bronchitis,  and  it  is  also  characteristic 
of  the  resolving  stage  of  pneumonia,  so  as  to  be  termed  the 
"  rale  redux."  When  present  only  in  the  apex  of  a  lung,  it  in- 
dicates a  tubercular  deposit.  It  accompanies  the  effusion  of 
blood  into  the  bronchial  tubes,  and  is  sometimes  present  in 
cedema  of  the  lungs. 


46 


PHYSICAL  DIAGNOSIS. 


Fig.  5.  The   Mucous   rale  is  also  a  moist 

bronchial  sound  produced  in  the  same 
way  as  the  sub-crepitant  rale ;  that  is, 
by  the  passage  of  air  through  mucus, 
pus,  serum,  blood,  etc. ;  so  that  the 
sound  may  be  termed  distiactly  liquid. 
It  differs,  therefore,  only  from  its  seat 
being  in  air  tubes  of  larger  size  than 
the  ultimate  capillary  bronchi  in 
which  originate  the  sub-crepitant  rale ; 
but  as  these  tubes  are  themselves  both 
small  and  large,  so  we  have  "  small," 
or  what  is  termed  "  fine "  mucous 
rales,  and  "  large  "  or  "  coarse  "  mu- 
cous rales.  Like  the  sub-crepitant 
rale,  you  may  hear  it  during  both  in- 
spiration and  expiration,  and  it  is 
Mucous  Rales,  Large  and  Small  modified,  or  entirely  removed,  by  the 
act  of  coughing.  Mucous  rales  occur  in  bronchitis  during  the 
stage  of  secretion ;  in  bronchial  hemorrhage ;  whenever  pus 
makes  its  way  into  the  air  passages  from  an  abscess, — ^in  short, 
whenever  the  bronchial  tubes  become  partially  filled  with 
fluid  of  any  kind,  and  hence  we  do  not  intend  to  imply  by  the 
term  "mucous"  that  it  is  only  the  mucous  secretion  itseK 
which  causes  the  rale.  If  these  rales,  whether  fine  or  coarse, 
are  restricted  to  a  circumscribed  space  at  the  apex  of  a  lung, 
they  indicate  that  the  bronchitis  is  secondary  to  tuberculosis. 

Gurgles  are  produced  in  larger  or  smaller  cavities  partially 
filled  with  liquid,  which  is  agitated  by  the  passage  of  air  from 
bronchial  tubes  that  communicate  freely  with  the  cavity  below 
the  surface  of  the  fluid.  This  sound,  though  distinctly  liquid, 
yet  has  a  pecuhar  hollow,  metallic  quality.  Gurgles  may  be 
heard  both  in  inspiration  and  expiration ;  and  according  to 
the  size  of  the  cavity  will  they  be  "  large  "  or  "small."     Small 


MUCOUS  CLICK. 


47 


gurgles  resemble  large  mucous  rales,  but  may  be  distinguislied 
from  them  by  their  above-mentioned  hoUow,  metalhc  char- 
acter. 

The  most  frequent  cause  of  pulmonary  cavities  is  the  soft- 
ening and  expectoration  of  a  tubercular  deposit;  but  they 
may  be  owing  to  abscess,  gangrene,  perforating  empyema, 
and  excessive  dilatation  of  the  bronchial  tubes.    "When  pul- 


Fig.  6. 


Gurglea 


Cavernous  Eespiration. 


Cavernous  Respiration  and  Gurgles. 

monary  cavities  exist  without  gurgles,  it  may  be  due  either  to 
the  cavity  being  filled  with  fluid,  or  to  its  containing  no  fluid ; 
or  the  level  of  the  fluid  may  be  below  the  opening  of  the 
bronchial  tubes. 

Mucous  Click.— This  is  a  single  quick,  chcking  sound,  not 
removed  by  coughing,  and  which  resembles  an  isolated  sub- 
crepitant  rale.  Authors  differ  as  to  the  theory  of  its  produc- 
tion. It  appears  to  me  to  be  due  to  the  sudden  and  forcible 
passage  of  air  through  a  smaU  bronchus,  the  sides  of  which 
have  been  brought  together  at  one  or  more  points,  either  by 
external  pressure,  or  by  their  being  agglutinated  fi^om  withm. 


48 


PHYSICAL  DIAGNOSIS. 


Tliis  happens  when  a  tubercular  deposit  presses  unequally 
upon  a  bronchus,  and  excites  at  the  same  time  a  local  inflam- 
mation of  the  mucous  membrane  of  the  part,  with  its  conse- 
quent viscid  secretion.  It  is  therefore  important  as  a  symptom 
of  incipient  phthisis. 

Pleuritic  Friction  Sounds. — These  also  are  properly  in- 
cluded among  the  adventitious  respiratory  sounds.  In  health, 
the  two  surfaces  of  the  pleural  membrane,  being  smooth,  and 


Fig.  7. 


Pleuritic  Friction 
Sound. 


Flatness  on  Per- 
cussion. Absence 
of  vocal  and  Res- 
piratory Sounds. 


Roughening  of  the  Pleura,  and  Slight  Pleuritic  Effusions. 


moistened  by  their  natural  secretion,  play  noiselessly  upon 
each  other  during  the  movements  of  each  respiratory  act. 
When  therefore  an  inflammation  roughens  either  one  or  both 
of  these  surfaces,  or  dries  up  their  natural  secretion,  it  gives 
rise  to  the  friction  which  produces  those  characteristic  sounds 
to  which  the  above  name  is  given.  These  sounds  are  few  in 
number  compared  to  crepitant  rales,  and  consist  of  one,  or  of 
a  series  of  abrupt,  jerking,  rubbing  noises,  manifestly  super- 


PLEURITIC  FRICTION  SOUNDS. 


49 


ficial,  and  whicli  are  commonlj  heard  over  a  limited  extent 
of  surface.  They  vary  much  in  intensity,  from  a  sound 
scarcely  audible,  to  one  of  extreme  loudness ;  and  they 
usually  accompany  both  inspiration  and  expiration,  being  sel- 
dom heard  with  expiration  alone. 

There  are  several  varieties  of  pleuritic  friction  sounds, 
termed,  respectively,  grazing,  rubbing,  grating,  creaking,  and 
cracHing;  all  of  which  belong  to  the  clinical  history  of 
pleurisy. 

The  grazing  variety  occurs  at  the  onset  of  pleurisy,  when 
dryness  of  the  membrane  is  the  only  change  yet  produced. 
As  soon  as  there  is  dulness  on  percussion,  it  is  replaced  by 
the  rubbing  or  crepitating  variety,  and  therefore  is  of  such 
short  duration,  that  it  is  not  often  heard,  but  may  be  more 
frequently  noticed  in  the  circumscribed  pleurisy  which  is 
sometimes  occasioned  by  tubercular  deposits.  The  other 
varieties  are  the  forms  in  which  the  pleuritic  friction  sound 
most  commonly  presents  itself ;  and  they  occur  both  in  the 
stage  of  plastic  exudation  and  in  the  stage  of  absorption. 


LESSON    VI. 

A.uscultation  of  the   Voice. 

This  is  anotlier  metliod  of  obtaining  information  as  to  the 
condition  of  the  lungs  and  their  investing  membranes,  and 
is  based  on  the  fact  that  the  vibrations  of  the  voice  are  not 
only  transmitted  outwards,  but  also  downwards  through  the 
trachea  and  bronchi,  to  all  parts  of  the  lung.  This  normal 
vocal  resonance,  as  it  is  termed,  varies  greatly  in  its  char- 
acter, according  to  where  it  is  heard  and  through  what 
media  it  has  passed  ere  it  reaches  the  ear  or  stethoscope  ;  and 
hence  its  varieties  are  named  after  the  parts  where  they  are 
heard  in  health. 

If  the  stethoscope  be  placed  over  the  larynx  or  trachea  of  a 
healthy  person,  while  speaking,  the  voice  will  be  transmitted 
to  the  ear,  imperfectly  articulated,  and  with  a  force,  intensity, 
and  concentration,  almost  painful.  This  is  called  Natural 
Laryngophony  and  Tracheophony. 

At  the  upper  part  of  the  sternum,  and  between  the  spines 
of  the  scapula,  it  is  heard  less  intense,  more  diffused,  and 
less  distinctly  articulated ;  and  this  is  termed  Bronchophony. 
But  when  you  apply  the  ear  over  lung  substance  itself,  the 
vibrations  of  the  voice  become  distant,  diffused,  and  without 
any  approach  to  articulation.  This  being  the  sound  peculiar 
to  lung  tissue,  the  term  normal  vocal  resonance  is  gen- 
erally applied  exclusively  to  it.  Its  intensity  is  always  greater 
on  the  right  than  on  the  left  side,  especially  in  the  infra-clavi- 
cular region.     But  it  also  varies  considerably  in  this  respect 


VOCAL  RESONANCE.  51 

in  different  healtliy  persons.  It  is  more  intense  in  tliose  wiio 
have  low-pitched  voices,  and  also  more  in  thin  than  in  fleshy 
persons  ;  while  in  females  there  is,  not  unfrequentlj,  no  differ- 
ence. You  cannot  rely  on  the  vocal  resonance  of  any  one 
region  of  the  chest,  as  trustworthy  evidence  by  itself,  either 
of  health  or  of  disease ;  the  indications  being  furnished  only 
by  comparisons  between  the  corresponding  parts  of  the  two 
sides,  after  allowance  is  made  for  natural  differences. 

In  making  your  examination  for  this  purpose,  the  readiest 
way  is  to  direct  the  patient  to  count  one,  two,  three,  etc.  The 
modifications  of  the  vocal  resonance  which  you  will  find 
indicative  of  disease  vsdll  consist  of  changes  in  intensity. 
1.  Its  intensity  may  be  diminished  ;  or,  2.  it  may  be  increased ; 
and  I  would  clasify  them  as  follows  : 

1.  DiminisliedJ  a  Vocal  sounds  may  be  weak  or  feeble, 
intensity.    .16"  "         "  suppressed  or  absent. 


2.  Increased 
intensity. 


'a  Vocal  sounds  may  be  simply  exaggerated. 
b  Its  resonance  may  be  of  the  character  termed  Bronchophony. 
,  c  "  "  "  "       Pectoriloquy. 

a  "  "  "  "       Egophony. 

g  «  "  "  "       Amphoric  Voice. 


The  varieties  included  under  the  head  of  diminished  reso- 
nance require  but  little  explanation.  The  vocal  resonance 
may  be  faint  or  altogether  wanting.  The  first  often  occurs  in 
bronchitis  with  free  secretion;  in  plastic  pleuritic  effusions, 
and  occasionally,  when  there  is  extreme  pulmonary  consolida- 
tion. There  is  absence  of  vocal  resonance  in  pneumo-thorax, 
and  in  copious  serous  pleuritic  effusion.  The  modifications, 
however,  which  accompany  increased  intensity  are  more  varied 
and  complex. 

Exaggerated  Vocal  Resonance  differs  from  normal  vocal 
resonance  only  in  a  slight  increase  of  intensity.  It  denotes  a 
moderate  amount  of  solidification  of  lung  tissue,  and  is  chiefly 
of  importance  in  the  diagnosis  of  tubercle. 


52  PHYSICAL  DIAGNOSIS. 

The  characters  of  Bronchophony  I  have  abeady  de- 
scribed. Its  significance  lies  in  its  being  found  in  localities 
where  it  is  not  heard  in  healthy  conditions  ;  its  near,  strong, 
and  distinct  sound  reaching  the  ear,  when  we  should  hear  in- 
stead the  distant,  muffled,  and  inarticulate  vibration  of  normal 
vocal  resonance.  This  could  not  have  happened  without  the 
spongy  tissue  of  the  lung  being  first  changed  to  a  denser 
texture,  better  adapted  to  transmit  the  sound  from  the  larger 
bronchi,  and  hence  it  denotes  complete  pulmonary  consolida- 
tion in  those  parts  where  it  is  abnormally  present.  The  best 
examples  of  bronchophony  are  usually  met  with  in  the  second 
stage  of  pneumonia. 

Pectoriloquy  (so  named  by  Laennec,  its  discoverer)  is  a 
complete  transmission  of  the  voice  to  the  ear.  The  words 
spoken  are  heard  distinctly  articulated.  It  closely  resembles 
the  resonance  heard  over  the  larynx,  and  is  usually  limited  to 
a  small  space  in  the  chest,  where  it  also  may,  or  may  not, 
have  a  hollow,  ringing  character.  It  was  formerly  beheved 
always  to  indicate  the  presence  of  a  pulmonary  cavity,  but 
auscultators  are  now  agreed  that  this  is  not  necessarily  the 
case  in  every  instance,  but  that  it  is  sometimes  simply  an 
exaggerated  bronchophony ;  the  only  distinction  between 
these  two  being  that  bronchophony  is  the  transmission  of  the 
voice,  pectoriloquy  that  of  the  speech.  Well  defined  pectori- 
loquy is  not  a  common  phenomenon. 

Egophony  is  the  name  given  by  Laennec  to  another  form 
of  vocal  resonance,  which  is  distinguished  by  its  tremulous, 
nasal  character,  suggestive  of  the  bleating  of  a  goat.  It  also 
is  a  modification  of  bronchophony.  Laennec  considered  it  a 
sign  of  a  limited  amount  of  plastic  effusion  in  the  pleura,  over 
sohdified  lung.  It  is  rarely  heard,  and  is  of  not  much  sig- 
nificance when  heard. 

Amphoric  Voice  is  a  term  applied  to  the  vocal  resonance, 
whenever,  in  addition  to  its  being  of  a  hollow,  metallic  char- 


WHISPER  RESONANCE.  53 

acter,  it  has  a  distinct  musical  intonation.  This  musical  sound 
follows  the  voice,  is  of  high  pitch,  and  is  not  articulated  like 
pectoriloquy.  It  is  sometimes  produced  in  large  cavities 
within  the  lung,  but  is  more  particularly  a  sign  of  pneumo- 
hydro-thorax. 

In  addition  to  vocal  resonance,  we  have  a  true  whisper  reso- 
nance, the  modifications  of  which  by  disease  may  afford  us 
some  valuable  hints  (as  was  first  pointed  out  by  Prof.  A, 
Flint).  If  while  practising  auscultation  on  a  person  in  health 
(as  I  should  strongly  advise  you  to  do  with  one  another  while 
studying  this  whole  subject),  you  direct  him  to  count  ia  a 
loud  whisper,  you  will  usually  hear  a  soft,  blowing  sound, 
accompanying  each  whispered  word,  which  varies  in  intensity 
in  different  persons. 

As  a  rule,  it  is  heard  only  at  the  upper  portion  of  the 
thorax,  and  is  loudest  over  the  primary  bronchi.  Dr.  FHnt 
calls  this  sound  the  normal  bronchial  whisper,  and  he  classes 
its  abnormal  modifications  into  exaggerated  bronchial  ivMsper, 
lohispering  hroncJiophony,  whispering  pectoriloquy,  cavernous 
whisper,  and  amphoric  whisper. 

The  exaggerated  differs  from  the  normal  whisper  in 
having  greater  intensity  and  higher  pitch.  It  indicates  slight 
solidification  of  lung  tissue.  In  whispering  bronchophony, 
the  blowing  sound  is  intense,  the  pitch  high,  and  the  sound 
seems  near  to  the  ear,  whUe  it  is  found  not  only  where  it 
should  be  in  health,  but  also  in  more  distant  parts,  where  it 
is  never  normally  present,  and  like  vocal  bronchophony  indi- 
cates complete  consolidation  of  the  lung  substance.  The 
cavernous  whisper  is  a  hollow,  low-pitched,  blowing  sound. 
It  is,  when  present,  a  trustworthy  indication  of  a  cavity,  and 
requires  similar  conditions  for  its  production  with  those  of 
cavernous  respiration.  In  whispering  pectoriloquy,  the  whis- 
pered words  are  distinctly  audible  at  the  surface  of  the  chest, 
and  this  constitutes  a  more  sure  indication  of  a  cavity  than 


g^  PHYSICAL  DIAGNOSIS. 

vocal  pectoriloquy.      The   character  and  the  significance  of 
the  amphoric  whisper  are  the  same  as  those  of  the  amphoric 

voice. 

Another  of  the  adventitious  sounds  is  that  which  is  termed 
metaUic  tinkling,  its  name  being  sufficiently  descriptive  of  its 
character.  It  sounds  like  the  dropping  of  a  pm  or  a  smaU 
shot  into  a  metaUic  vessel.  A  single  one,  or  a  series  of  tink- 
ling sounds,  may  be  produced  by  the  act  of  speaking,  or 
by  the  movements  of  inspiration  and  expiration;  but  it  is 
especially  consequent  on  the  act  of  coughing. 

This  sound  announces  the  existence  either  of  a  very  large 
pulmonary  cavity,  or  of  pneumo-hydro-thorax.  Dr.  Walsh 
regards  it  as  the  echo  of  a  bubble  bursting  in  a  liquid,  shut 
up  in  a  spacious  cavity  which  also  contains  air. 

Resonance  of  Cough. — If  while  auscultating  a  healthy 
person  you  cause  him  to  cough,  you  will  find  the  act  accom- 
panied by  a  quick,  sharp,  indistinct  sound,  which  jars  through 
the  whole  chest.  Over  the  larynx  and  trachea  the  cough  is 
hoUow,  and  varies  in  pitch  and  intensity  with  the  voice  of  the 
individual.  The  modifications  of  the  cough  sound  in  disease 
are  termed  bronchial,  cavernous,  and  amphoric.  Bronchial 
cough  has  a  quick,  harsh  character,  attended  by  a  marked 
thrill  or  fremitus  in  the  chest.  Cavernous  cough  is  hoUow 
and  metallic  (commonly  it  is  termed  sepulchral).  It  may  be 
accompanied  by  gurgles,  and  its  resonance  is  sometimes  trans- 
mitted to  the  ear  of  the  auscultator  with  painful  intensity. 
Amphoric  cough  is  a  loud  resounding  sound,  of  metaUic  char- 
acter, but  not  forcibly  transmitted  to  the  ear.  It  conveys  the 
impression  of  a  large  empty  space.  These  varieties  of  cough 
are  heard  under  the  same  conditions  as  the  corresponding 
varieties  of  respiration.  They  are  not  of  much  utility  in 
diagnosis. 


LESSON    VII. 

^    Synopsis    of   Thysicat    Signs    in    the    Diaffuosis    of 
Pulmonary  diseases. 

Bronchitis. 

Acute  and  Chronic  Bronchitis  affecting  the  Larger  Tubes. 

Inspection. — The  form  and  movements  of  the  chest  are  not 
visibly  altered. 

Palpation. — Vocal  fremitus  is  normal;  occasionally  a  dis- 
tinct bronchial  fremitus  is  communicated  to  the  surface  of  the 
chest. 

Percussion. — Pulmonary  resonance  is  normal,  unless  there 
is  a  very  considerable  accumulation  of  mucus  in  the  bronchial 
tubes,  in  which  case  the  normal  resonance  is  diminished,  in 
the  lower  and  posterior  regions. 

Auscultation. — The  respiratory  murmur  is  feeble  or  tem- 
porarily suppressed  in  the  lung  tissue  corresponding  to  the 
affected  tubes.  In  the  dry  stage,  sibilant  and  sonorous  rales 
may  be  heard  on  both  sides  of  the  chest  (as  shown  in  fig.  3). 
In  the  stage  of  secretion  along  with  the  sibilant  and  sonorous 
rales,  mucous  rales,  large  and  small,  are  heard  on  both  sides  of 
the  chest  (see  fig.  5).  These  rales  are  inconstant,  coming  and 
going,  and  changing  their  situation.  When  the  rales  are  in- 
tense and  abundant,  they  altogether  mask  the  respiratory 
murmur.  In  some  cases  of  slight  bronchitis  of  the  larger 
tubes,  there  are  no  distinct "  rales,  but  the  respiration  has  a 
sonorous  character.     The  vocal  resonance  is  normal. 


56  PHYSICAL  DIAGNOSIS. 

Capillary  Bronchitis. 

Capillary  Bronchitis,  or  bronchitis  affecting  the  ultimate 
or  capillary  bronchial  tubes. 

In  addition  to  the  signs  belonging  to  simple  bronchitis, 
auscultation  discovers,  if  the  disease  is  extensive,  that  the 
vesicular  murmur  is  weakened  or  suppressed,  and  instead, 
sub-crepitant  rales  (see  fig.  4)  are  heard  on  both  sides  of  the 
chest,  accompanied  by  sibilant  rales  of  a  hissing  character. 
If  the  sub-crepitant  rales  are  abundant,  they  indicate  very 
'positively  that  the  capillary  bronchial  tubes  are  inflamed ;  but 
they  may  be  present  to  a  limited  extent  posteriorly,  owing  to 
the  gravitation  of  fluid  from  the  larger  to  the  smaller  tubes. 
If  they  are  confined  to  the  base  or  apex  of  one  lung,  with 
resonance  on  percussion,  the  bronchitis  is  either  of  an  em- 
physematous or  tubercular  origin, 

Fercussion  is  normal,  or  it  may  be  slightly  exaggerated. 

Vocal  Resonance  is  normal. 

Differential  Diagnosis  of  Bronchitis. — The  diagnosis  of 
bronchitis  of  the  larger  tubes  is  readily  made  ;  but  capillary 
bronchitis  may  be  confounded  with  pneumonia,  and  with 
acute  or  chronic  phthisis.  It  is  distinguished  from  pneu- 
monia, by  normal  or  exaggerated  resonance  on  percussion,  by 
the  existence  of  sub-crepitant  rales  on  both  sides  of  the  chest, 
and  by  the  absence  of  bronchial  breathing. 

The  distinctive  diagnosis  between  capillary  bronchitis  and 
phthisis,  will  be  considered  under  the  head  of  Phthisis. 

Dilatation  of  Bronchi, 

Dilatation  of  the  Bronchial  Tubes  very  frequently  occurs 
as  a  result  of  chronic  bronchitis,  and  is  recognized  by  the 
following  physical  signs  : 

Inspection  shows  defective,  expansive  movements  of  the 
chest,  and  prolonged,  labored  expiratory  movements. 


PULMONARY  EMPHYSEMA. 


57 


Palpation. — Yocal  fremitus  normal,  rhoncliial  fremitus  fre- 
quently present. 

Percussion  is  normal,  unless  the  accumulation  of  tliick 
secretion  gives  rise  to  obstruction  of  the  tubes,  and  consequent 
imperfect  inflation  of  the  lungs ;  in  such  cases,  there  is  tempo- 
rary dulness.  This  dulness  is  to  be  distinguished  from  the 
dulness  of  pleuritic  effusion,  by  its  temporary  character,  and 
by  the  continuance  of  vocal  fremitus.  From  pneumonic 
consolidation  it  is  distinguished  by  the  absence  of  bronchial 
breathing. 

Auscultation. — The  normal  respii-atory  sounds  are  compar- 
atively deficient  over  the  entire  chest,  except  after  free  expec- 
toration, when  they  may  be  heard  harsh  and  loud,  where  a 
moment  before  they  were  inaudible.  The  respiratory  sounds 
are  accompanied  by  a  variety  of  rales,  chiefly  sonorous,  unless 
the  tubes  have  just  been  emptied,  when  large  mucous  rales  or 
gurgles  are  also  present.  The  sounds  in  any  portion  of  the 
lung  are  constantly  varying  in  character,  altered  by  cough 
and  by  full  inspiration. 

Vocal  Resonance  is  usually  normal ;  it  may  be  entirely 
absent  in  the  parts  where  dulness  exists. 

JPulinonary  Emphysema, 

Inspection  in  a  well-marked  example  of  this  disease  dis- 
covers altsrations  in  the  shape  and  movements  of  the  chest. 
The  sternum  is  often  abnormally  prominent  as  if  fi'om  congen- 
ital deformity.  There  is  bulging  of  the  infra-clavicular  and 
mammary  regions,  which  gives  to  the  upper  portion  of  the 
chest  a  more  rounded  appearance  than  in  health,  or,  as  it  is 
called,  "  barrel-shaped."  The  shoulders  are  elevated  and 
brought  forwards ;  there  is  more  or  less  anterior  curvature  of 
the  spine,  and  the  person  appears  to  stoop.  The  lower  por- 
tion of  the  chest  seems  contracted,  and  the  intercostal  spaces 
are  widened  in  the  upper,  narrowed  in  the  lower  spaces.    In 


58  PHYSICAL  DIAGNOSIS. 

some  instances  in  which  the  general  symptoms  of  emphysema 
are  well  marked,  the  lung  is  atrophied  instead  of  being  abnor- 
mally dilated ;  and  no  bulging  or  prominence  of  the  chest 
occurs  either  general  or  local. 

The  movements  of  the  chest  walls  are  also  altered ;  at  the 
upper  portion,  expansion  on  inspiration  is  diminished  or  en- 
tirely wanting  ;  the  whole  chest  moves  vertically  up  and  down 
with  inspiration  and  expiration,  as  if  it  were  passively  lifted 
from  the  shoulders,  and  composed  of  one  sohd  piece ; 
while  below,  the  chest,  instead  of  being  dilated  with  inspira- 
tion, is  contracted.  The  respiratory  efforts  are  labored,  and' 
the  breathing  is  chiefly  abdominal. 

Palpation. — The  vocal  fremitus  varies ;  it  may  fall  below,  or 
it  may  equal,  or  exceed,  the  average  of  health.  The  apex  beat 
of  the  heart  is  often  not  perceptible  in  the  precordial  space ; 
sometimes  it  is  felt  much  lower  than  its  normal  position. 

Mensuration  shows  a  marked  increase  in  the  antero-poste- 
rior  diameter  of  the  chest. 

Percussion. — The  intensity  of  the  percussion  sound  is  in- 
creased ;  the  pitch  is  lowered ;  the  pidmonary  quahty  of  the 
sound  is  greatly  diminished,  and  it  becomes  what  has  already 
been  described  as  vesiculo-tympanitic.  The  percussion  note 
is  not  materially  affected  either  by  forced  inspiration  or  forced 
expiration. 

Auscultation. — As  a  rule,  the  inspiratory  sound  is  either 
short  and  feeble,  or  actually  suppressed,  and  the  expiratory 
sound  is  greatly  prolonged ;  the  ratio  of  the  two  sounds  being 
as  1:4  instead  of  4:1.  The  pitch  of  both  inspiratory  and  expi- 
ratory sounds  is  lower  than  in  health. 

In  some  extreme  cases  of  emphysema,  the  respiratory 
sounds  are  of  equal  length,  greatly  exaggerated  in  intensity, 
and  of  a  harsh,  sibilant  quality,  the  harsh  quality,  undoubt- 
edly, being  due  to  diminution  in  the  calibre  of  the  minute 
bronchial  tubes. 


ACUTE  PNEUMONIA. 


59 


Vocal  Resonance  varies  greatly;  sometimes  it  is  dimin- 
ished or  altogether  absent ;  at  others,  its  intensity  is  greatly 
increased.  The  heart  sounds  are  feeble,  and  in  rare  instances 
the  organ  is  pushed  downwards  towards  the  epigastrium. 

Differential  Diagnosis. — The  only  disease  with  which  em- 
physema is  liable  to  be  confounded  is  pneumo-thoras.  The 
distinction,  however,  is  not  very  difficult,  for  in  emphysema 
the  percussion  sound,  although  tympanitic,  stiU  retains  a  pul- 
monary quaUty,  and  there  is  a  vesicular  element  to  the  respi- 
ratory sound ;  while  in  pneumo-thorax  the  percussion  sound 
has  a  complete  tympanitic  character,  and  the  respiration,  if 
audible,  is  amphoric.  Besides,  pneumo-thorax  affects  only 
one  side,  emphysema  both. 

Spasmodic  Astlima  (during  the  Paroxysm). 

Inspection  shows  labored  respiration. 

Palpation,  vocal  fremitus  normal. 

Percussion  is  normal  or  exaggerated. 

Auscultation. — The  rhythm  of  the  respiratory  murmur  is 
jerking  and  irregular  ;  sometimes  it  is  exaggerated,  at  others 
it  is  suppressed.  Sibilant  and  sonorous  rales,  of  a  high 
pitched,  hissing  and  wheezing  character,  are  diffused  over  the 
whole  chest,  often  loud  enough  to  be  heard  at  a  distance. 

Vocal  Resonance  is  normal. 

Acute  I*neunionia. 

The  physical  signs  of  pneumonia  vary  with  its  different 
stages. 

First  Stage,  or  Stage  of  Engorgement.— Inspection.— 
The  movements  of  the  affected  side  are  more  or  less  re- 
strained. 

Palpation,  vocal  fremitus  normal. 

Percussion.— There  is  slight  dulness  over  so  much  of  lung 


60 


PHYSICAL  DIAGNOSIS. 


tissue  as  is  involved  in  the  pneumonic  inflammation,  the  de- 
gree of  dulness  depending  upon  the  amount  of  exudation  into 
the  lung  substance. 

Auscultation. — In  the  early  period  of  the  engorgement  be- 
fore exudation  takes  place,  the  respii*atory  murmur  is  dimin- 
ished in  intensity  in  the  affected  pai*t,  and  exaggerated  in 
other  portions  of  the  affected  lung,  as  well  as  in  the  healthy 
lung.  As  soon  as  exudation  takes  place,  the  inspiratory 
sound  is  accompanied  by  the  crepitant  rale,  the  characteristic 
sign  of  the  first  stage  of  pneumonia.  In  some  cases,  especially 
when  pneumonia  is  developed  in  connection  with  acute  artic- 
ular rheumatism,  crepitation  never  occurs. 

Fig.  8. 


1st  stage. 


j  Slight 
(  Crepit 


ght  dulness   . 
Crepitant  rale.    J^- 


2d  Stage. 


I  Complete  dulness.     .    .    . 
J  Bronchial  respiration.  .     . 

1  Bronchophony 

\  Increased  vocal  fremitus. 


Diminished  dulness.  .     . 
Sub-Crepitant  rale.     .    . 
3d  Stage.  -^     Broncho-vesic  respiration. 
Increased  vocal  resonance. 
Increased  vocal  fremitus. 


Dioujram  illustrative  of  tlic  PInjsical  Signs  of  the  Three  Stages  of  Pneumonia. 

Second  Stage,  or  Red  Hepatization.— Inspection.— The 

expansive  movements  are  diminished  on  the  affected  side,  and 
increased  on  the  healthy. 

Palpation. — As  a  rule,  vocal  fremitus  is  increased;  occa- 
sionally, w^hen  the  hepatization  is  extensive,  it  is  diminished. 

Percussion.— There  is  marked  dulness  over  a  space  corre- 


HEPATIZATION. 


61 


spending  to  the  consolidated  lung  tissue,  and  increased  reso- 
nance over  the  healthy  portion  of  the  affected  lung.  The 
relation  of  the  resonance  and  dulness  is  not  affected  by  a 
change  in  the  position  of  the  patient.  Absolute  dulness  or 
flatness  on  firm  percussion  very  rarely  exists. 

Auscultation. — As  the  air  cells  become  completely  filled 
with  exudation,  the  crepitant  rales  cease,  and  bronchial  respi- 
ration is  heard  over  the  sohdified  lung  tissue.  The  more  com- 
plete the  consohdation,  the  more  intense  and  tubular  is  the 
bronchial  respiration. 

Vocal  Resonance. — There  is  markedbronchophony overall 
that  portion  of  lung  which  is  the  seat  of  pneumonic  consolida- 
tion. The  heart  sounds  are  transmitted  to  the  surface  with 
unnatural  intensity.  The  characteristic  physical  signs  of  this 
stage  are  dulness  on  percmsion,  bronchial  breathing,  and  broncho- 
phony. 

Third  Stage,  or  Grey  Hepatization.— The  physical  signs 
in  the  early  part  of  this  stage  are  the  same  as  those  of  the 
second  stage.  They  are  simply  the  signs  of  consohdation. 
In  the  latter  or  resolving  part  of  this  stage,  percussion  shows 
progressive  diminution  in  dulness.  It  is  often,  however,  a  long 
time  before  normal  pulmonary  resonance  is  perfectly  restored. 

Auscultation. — The  bronchial  respiration  of  the  second 
stage  gradually  gives  place  to  rude  (or  broncho-vesicular) 
respiration,  and  this  in  turn  approximates  to,  and  at  length 
ends  in,  normal  vesicular  breathing.  As  the  bronchial  respi- 
ration diminishes,  the  sub-crepitant  and  crepitant  rales,  or 
"  rales  redux,"  are  developed,  and  remain  audible  until  resolu- 
tion is  complete. 

Bronchophony  gives  place  to  exaggerated  vocal  resonance, 
and  that  in  turn  to  normal  vocal  resonance.  The  physical 
signs  of  chronic  pneumonia  will  be  considered  in  connection 
with  phthisis. 


62-  PHYSICAL  DIAGNOSIS. 

JPulnionary  (Edema, 

In  oedema  of  the  lungs  inspection  and  palpation  furnisli  no 
positive  information. 

Percussion. — There  is  more  or  less  dulness  on  percussion 
(never  however  complete)  diffused  over  the  posterior  surface 
of  the  chest  on  both  sides,  and  marked  at  the  most  depending 
portion  of  the  lungs. 

Auscultation. — Respiratory  murmur  is  feeble,  sometimes 
almost  entirely  absent.     With  the  inspiratory  sound,  crack- 
ling rales  are  heard  over  the  seat  of  the  oedema ;  the  crackhng  • 
resembles  somewhat  the  crepitant  rale  of  j)neumonia,  but  is 
distinguished  from  it  by  its  hquid  character. 

DiJBFerential  Diagnosis. — Pulmonary  oedema  may  be  con- 
founded with  the  fii'st  stage  of  pneumonia,  with  hydro-thorax, 
and  with  capillary  bronchitis.  It  is  distinguished  from  pneu- 
monia, as  we  mentioned  above,  by  the  liquid  character  of  the 
crackling  rales,  and  by  its  occurring  on  both  sides,  at  the 
most  depending  portion  of  the  lungs, — pneumonia  usually 
being  confined  to  one  lung ;  from  hydro-thorax,  by  the  pres- 
ence of  rales,  and  by  the  level  of  the  dulness  not  being 
changed  by  a  change  in  the  position  of  the  patient ;  from 
capillary  bronchitis,  by  the  slight  dulness  on  percussion 
which  attends  it,  and  by  the  absence  of  the  rales  in  the  larger 
bronchial  tubes. 

Pulmonary  Gangrene. 

The  physical  signs  of  pulmonary  gangrene  are  often  ob- 
scure and  never  distinctive.  They  are  those  of  local  consoli- 
dation followed  by  the  evidences  of  the  breaking  up  of  lung 
tissue,  and  the  formation  of  cavities  in  the  lung  substance. 
There  are  no  special  signs  indicating  the  nature  of  the  disor- 
ganizing process;  sometimes  it  is  preceded  by  the  signs  of 


PULMONAET  HEMORRHAGE.  g3 

pneumonia ;  generally  it  is  accompanied  by  the  signs  of 
bronchitis,  and  late  in  the  disease  there  are  physical  evidences 
of  the  formation  of  cavities  in  the  lung  substance. 

Pulmonary  Hemorrhage. 

The  physical  signs  of  a  slight  hemorrhage  from  the  lungs 
are  very  obscure.  No  information  as  to  the  seat  or  amount 
of  the  hemorrhage  is  furnished  by  inspection,  palpation,  or 
percussion.  Auscultation  may,  however,  indicate  the  spot  at 
which  the  hemorrhage  occurs,  by  the  presence  of  mucous 
rales.  If  the  hemorrhage  is  profuse,  and  accompanied  by  pul- 
monary apoplexy,  abundant  mucous  rales  will  be  heard  at  the 
seat  of  the  effusions,  and  they  remain  audible  until  coagula- 
tion takes  place,  or  the  effusion  is  removed.  When  pulmo- 
nary apoplexy  occurs,  it  is  usually  found  in  the  lower  and 
posterior  portions  of  the  lungs.  If  the  nodules  are  few  and 
small,  there  will  be  no  positive  physical  evidences  of  their  situ- 
ation. When  the  nodules  are  large  and  he  superficially,  per- 
cussion will  give  more  or  less  dulness  over  a  Hmited  space 
corresponding  to  the  extent  of  the  hemorrhage,  and  on  aus- 
cultation there  will  be  a  diminution  or  absence  of  the  respi- 
ratory murmur.  When  the  extravasation  is  situated  near  a 
large  sized  bronchial  tube,  bronchial  breathing  and  increased 
vocal  resonance  are  heard,  and  there  is  also  increase  in  the 
vocal  fremitus. 

Cancer  of  the  Lung 

Is  marked  by  the  signs  of  sohdification  in  a  greater  or  less 
degree,  and  more  or  less  diffused.  The  affected  side  is  flat- 
tened, or  generally  retracted,  and  the  respiratory  movements 
are  impaired. 


LESSON    VIII. 

A.  Synopsis  of  Physical  Signs  in  the  Diagnosis  of  'Pulmo- 
nary Diseases. — Continued. 

Pleurisy. 

Theke  are  three  recognized  varieties  of  pleurisy,  Acute,  Sub- 
Acute,  and  Chronic,  or  Empyema.  In  acute,  there  is  but 
Httle  liquid  effusion;  in  sub-acute,  the  liquid  effusion  is 
abundant,  often  completely  filUng  the  pleuritic  cavity ;  in 
empyema  the  effusion  is  purulent,  comparatively  small  in 
quantity,  and  usually  circumscribed.  I  shall  consider  the 
physical  signs  of  the  three  varieties  separately. 

Acute  Pleurisy 

May  be  divided  into  four  stages, — a  dry  stage,  a  plastic 
stage,  a  stage  of  liquid  effusion,  and  a  stage  of  absorption. 

Dry  Stage. — Inspection  shows  a  diminution  in  the  respira- 
tory movements,  especially  in  expansion  of  the  affected  side. 
They  are  also  quick,  catching,  and  irregular.  Palpation,  men- 
suration, and  percussion,  yield  only  negative  results. 

Auscultation. — The  respiratory  murmur  is  feeble,  jerking, 
and  interrupted ;  occasionally  a  grazing,  friction  sound  is 
heard  over  the  seat  of  the  pleuritic  inflammation. 

Stage  of  Plastic  Exudation. — Inspection. — The  respira- 
tory movements  of  the  affected  side  are  still  more  diminished; 
while  those  of  the  healthy  side  are  increased. 

Palpation — Vocal  fremitus  is  diminished. 


ACUTE  PLEURISY.  gg 

Percussion.— There  is  more  or  less  dulness  over  the  seat  of 
the  plastic  exudation.  If  the  dulness  is  marked,  the  plastic 
matter  is  abundant.  The  dulness  will  be  less  at  the  end  of  a 
full  expiration. 

Auscultation. — The  respiratory  murmur  over  the  seat  of 
the  pleuritic  inflammation  is  feeble  or  entu-ely  absent,  and  a 
rubbing  or  crepitating  friction  sound  is  heard,  most  distinctly 
at  the  end  of  the  inspiratory  act,  as  shown  in  fig.  7. 

Vocal  Resonance. — The  intensity  of  the  vocal  resonance 
is  diminished. 

Stage  of  Liquid  Effusion. — Inspection. — In  acute  pleurisy 
the  quantity  of  hquid  effusion  is  generally  small,  as  shown  in 
fig.  7  ;  consequently  there  is  no  dilatation  of  the  affected  side. 
The  jerking  movements  of  the  dry  and  plastic  stage  now 
cease,  and  there  is  no  visible  motion  at  the  seat  of  the  fluid 
accumulation. 

Palpation. — Vocal  fremitus  is  absolutely  suppressed  over 
the  effused  fluid. 

Percussion. — ^When  the  patient  is  sitting  or  standing,  there 
is  flatness  on  percussion,  from  the  base  of  the  lung  on  the 
affected  side,  to  the  level  of  the  fluid,  as  shown  in  fig.  7. 
The  line  of  the  flatness  may  be  changed  by  changing  the 
position  of  the  patient. 

Auscultation. — The  respiratory  sounds  below  the  level  of 
the  fluid  are  suppressed,  above  they  are  exaggerated.  The 
friction  soimds  disappear  where  the  fluid  effusion  prevents  the 
pleural  surfaces  from  coming  in  contact  with  each  other,  but 
above  the  confines  of  the  fluid  they  continue  to  be  heard,  as 
shown  in  fig.  7. 

Vocal  Resonance. — Below  the  level  of  the  fluid,  aU  vocal 
sounds  are  abolished. 

Stage  of  Absorption — This  stage  is  marked  by  the  gi-ad- 
ual  return  of  pulmonary  resonance  on  percussion,  and  of  the 
normal  vocal  and  respiratory  sounds.    As  the  fluid  effusion 


gg  PHYSICAL  DIAGNOSIS. 

disappears,  creaking  friction  sounds  are  audible  for  a  brief 
period. 

Sub-Acute  Pleurisy, 

In  this  variety  of  pleurisy,  the  pleural  cavity  may  be  partly 

or  completely  filled  with  fluid.     Besides  the  fluid  there  is  a 

moderate  amount  of  plastic  exudation,  which  thickens  and 

roughens  the  pleural  membranes.     When  the  cavity  is  partly 

filled,  the  presence  and  amount  of  the  effusion  is  determined  by 

the  same  physical  signs  that  mark  the  effusive  stage  of  acute 

pleurisy.     When  the  pleural  sac   is  distended   by  the  fluid 

accumulation,   the  lung    is   compressed    against    the   spiual 

column,  and  the  capacity  of  the  pleural  cavity  is  increased  in 

every  direction,  giving  rise  to  important  modifications  in  the 

physical  signs. 

Fig.  9. 


Absence  of  respiratory  sounds, 
"  "  vocal  Bounds.  .  . 
"       "   vocal  fremitus. 


Flatness  on  percussion. 


Diagram  showing  the  Pleural  Cavity  completely  filled  with  Fluid,  the  Lung  being  compressed. 

Inspection  shows  perfect  immobility  of  the  chest  walls,  with 
general  enlargement  of  the  affected  side ;  the  intercostal  spaces 
are  even  with  the  ribs,  or  bulging,  and  the  cardiac  impulse  is 
visible  in  an  abnormal  position. 


SUB-ACUTE  PLEURISY. 


67 


Mensuration  shows  an  enlargement  of  the  affected  side, 
both  in  its  circumference  and  in  its  antero-posterior  diameter ; 
the  enlargement  is  greatest  over  the  false  ribs,  the  affected 
side  often  measuring  three  or  four  inches  more  than  the 
healthy. 

Palpation  shows  the  vocal  fremitus  to  be  wanting. 

Percussion. — There  is  universal  flatness  on  percussion  over 
the  affected  side,  the  flatness  extending  beyond  the  natural 
limits  of  the  lung.  Under  the  clavicle,  the  percussion  sound 
sometimes  has  a  tympanitic  quality. 

Auscultation. — There  is  entire  absence  of  all  respiratory 
and  vocal  sounds  over  the  affected  side,  except  over  the  apex 
of  the  compressed  lung ;  here  not  unfrequently  are  heard  bron- 
chial respiration  and  bronchophony  ;  the  bronchial  respiration 
emanating  from  the  compressed  lung  is  diffused,  and  may  be 
heard  over  the  whole  of  the  affected  side.  The  respiratory 
sound  over  the  healthy  lung  is  exaggerated. 

In  the  Fourth  Stage,  or  stage  of  absoi-ption,  inspection  in- 
forms us  that  the  enlargement  of  the  affected  side  is  disap- 
pearing ;  that  the  intercostal  spaces  are  regaining  their  normal 
condition,  and  that  the  respiratory  movements  of  the  chest 
walls  are  returning,  although  restricted. 

Palpation  shows  a  gradual  return  of  vocal  fremitus. 

Mensuration  shows  a  gradual  diminution  in  the  measure- 
ment of  the  affected  side,  until  it  becomes  even  less  than  the 
opposite  side. 

Percussion. — The  percussion  sound  gradually  recovers  its 
normal  resonance ;  first,  at  the  upper,  and  then  at  the  lower 
portion  of  the  pleural  cavity ;  sometimes  in  the  inferior  por- 
tion it  never  regains  its  normal  resonance,  owing  to  the  great 
accumulation  of  solid,  plastic  material. 

Auscultation. — The  respiratory  sounds  are  again  heard,  at 
first  weak  and  distant ;  gradually  they  become  more  distinct, 
and  sometimes  harsh  in  character.    As  the  absorption  of  the 


68  PHYSICAL  DIAGNOSIS. 

fluid  takes  place,  and  tlie  two  surfaces  of  the  pleura  again 
come  in  contact,  a  friction  sound  returns  of  a  creaking,  crepi- 
tating character,  which  remains  audible  for  a  variable  period. 
The  vocal  resonance  is  at  first  bronchophonic,  then  exaggerated, 
and  ultimately  you  get  normal  vocal  resonance.  The  heart, 
with  the  adjacent  abdominal  viscera,  returns  to  its  normal 
position,  sometimes  with  singular  promptness.  If,  as  some- 
times happens,  the  lung  remains  permanently  impervious  to 
air,  then  there  is  a  permanent  loss  of  motion  on  the  affected 
side,  and  there  is  no  return  of  the  respiratory  or  vocal  sounds, 
while  dulness  on  percussion  is  persistent.  A  portion  of  the 
lung  (usually  the  upper  portion)  sometimes  becomes  partially 
pervious  to  air ;  when  this  is  the  case,  the  percussion  sound 
over  it  will  have  a  tympanitic  quality,  the  vocal  resonance 
will  be  exaggerated,  and  the  respiratory  sound  coarse  and 
blowing. 

Empyema, — The  physical  signs  of  empyema  are  the 
same  as  those  of  sub-acute  pleurisy,  when  the  pleural  cavity 
is  partially  filled  with  fluid.  In  the  majority  of  the  cases  of 
empyema  that  have  come  under  my  observation,  a  change 
iu  the  position  of  the  patient  has  not  caused  a  change  in  the 
level  of  the  fluid,  owing  probably  to  the  firm  adhesion  that 
takes  place  between  the  pleura  pulmonalis  and  pleura  costalis, 
above  the  level  of  the  prevalent  accumulation. 

Differential  Diagnosis. — The  diagnosis  of  pleurisy,  in  the 
majority  of  cases,  is  easily  made;  yet  in  aU  its  different 
varieties  there  is  some  danger  of  confounding  it  with  other 
diseases. 

In  the  Dry  Stage  of  acute  pleurisy,  it  may  be  confounded 
with  pleurodynia,  and  intercostal  neuralgia  ;  it  is  distinguished 
from  them  by  the  presence  of  the  grazing  friction  sound,  by 
the  deep-seated  character  of  the  pain,  and  by  the  absence  of 
tenderness  on  pressure  over  the  seat  of  pain. 

The  Plastic  Stage  of  pleurisy  on  the  left  side  may  occa- 


SUB-ACUTE  PLEURISY.  69 

sionally  be  confounded  with  the  plastic  stage  of  pericarditis. 
It  is  readily  distinguished  from  it  by  the  cessation  of  the 
friction  sound  during  a  temporary  suspension  of  the  respira- 
tory movements. 

The  EflFusive  Stage  may  be  confounded  with  consohda- 
tion  of  the  lung  from  pneumonia  and  tubercular  infiltration, 
with  an  enlarged  liver  or  spleen  extending  upwards,  and 
with  cancerous  deposits  in  the  lungs.  It  is  distinguished 
from  pneumonia  and  tubercular  consolidation  by  the  bulging 
of  the  affected  side,  by  the  absence  of  vocal  fremitus,  by 
the  flatness  of  the  percussion  sound,  by  the  change  in  the 
level  of  the  fluid  on  change  in  the  position  of  the  patient, 
and  by  the  absence  of  aU  vocal  and  respiratory  sounds.  The 
blowing  respu'ation  that  is  sometimes  heard  over  a  pleural 
cavity  fiUed  with  fluid  differs  from  the  true  tubercular  or 
bronchial  breathing  of  pulmonary  consolidation,  in  being  more 
diffused  and  deep-seated,  and  not  being  accompanied  by  any 
moist  sounds.  In  tubercular  infiltration,  the  progress  of  the 
physical  signs  is  usually  from  above  downwards  ;  in  effusion, 
they  advance  from  below  upwards.  Besides,  tubercular  dis- 
ease of  an  entire  lung  does  not  exist  without  involving  the 
opposite  lung;  while  any  amount  of  pleuritic  effusion  may 
exist  on  one  side,  while  the  other  remains  unaffected. 

The  physical  signs  of  the  stage  of  absorption  will  rarely  be 
confounded  with  any  other  disease.  Hypertrophy  of  the  Hver, 
enlarging  upwards,  is  distinguished  from  effusion  into  the 
right  pleural  cavity  by  the  existence  of  pulmonary  percus- 
sion, and  audible  respiratory  murmur  at  the  posterior  part  of 
the  chest.  Deep  inspiration  also  increases  the  area  of  the 
normal  percussion,  and  normal  respiratory  sound  at  the  infe- 
rior portion  of  the  pleural  cavity ;  it  exerts  no  such  influence 
when  the-  loss  of  resonance  and  respiratory  murmur  depends 
upon  pleuritic  effusion. 

Enlargement  of  the  spleen  affects  but  slightly  the  vocal  or 


YO  PHYSICAL  DIAGNOSIS. 

respiratory  sounds  at  the  inferior  portion  of  the  left  pleural 
cavity ;  it  causes  no  protrusion  of  the  intercostal  spaces,  and 
does  not,  hke  pleuritic  effusion,  push  the  heart  to  the  right, 
but  raises  it  upwards. 

Pneumo-Thorax. — Inspection  shows  distension  of  the  affect- 
ed side,  widening  and  bulging  of  the  intercostal  spaces,  and 
immobility  of  the  chest  walls,  contrasting  forcibly  with  the 
costal  movements  of  the  healthy  side. 

Palpation. — Vocal  fremitus  is  diminished,  or  altogether 
wanting.  Mensuration  shows  marked  increase  in  the  measure- 
ment of  the  affected  side. 

Percussion  ehcits  a  tympanitic  resonance  of  an  amphoric 
or  metallic  quahty,  over  the  whole  of  the  affected  side. 
When  the  dilatation  of  the  chest  is  excessive,  the  adjacent 
viscera  are  more  or  less  displaced,  the  tympanitic  percussion 
sound  assumes  a  muffled  character,  and  extends  considerably 
beyond  the  normal  Hmits  of  the  pleura. 

Auscultation  varies  according  to  the  amount  of  air  con- 
tained in  the  pleural  cavity.  If  the  cavity  is  distended  with 
air,  so  that  the  lung  is  completely  compressed,  the  vocal  and 
respiratory  sounds  are  altogether  absent,  and  the  heart  sounds 
are  feebly  transmitted  through  the  distended  pleura ;  if  the 
quantity  of  air  is  small,  the  respiratory  sounds  are  weak  and 
distant,  and  the  vocal  sounds  indistinct. 

Hydro-pnemno -Thorax  usually  is  the  result  of  perfora- 
tion of  the  pleura ;  a  communication  being  estabhshed  between 
a  bronchial  tube  and  the  pleural  cavity.  The  physical  signs  of 
this  condition  are  a  combination  of  those  of  pleuritic  effusion 
and  pneumo-thorax.  As  in  pneumo-thorax,  inspection  reveals 
dilatation  of  the  affected  side,  dulness  and  bulging  of  the 
intercostal  spaces,  immobility  of  the  chest  walls,  and  dis- 
placement of  the  heart  and  adjacent  viscera.  There  is  entire 
absence  of  vocal  fremitus. 


PHTHISIS  PULMONALIS. 


71 


Percussion. — ^TVlien  the  patient  is  sitting  or  standing,  there 
will  be  tympanitic  resonance  on  percussion  from  the  summit 
of  the  affected  side  to  the  level  of  the  fluid,  and  flatness 
below  ;  the  relation  of  the  flatness  and  tympanitic  resonance 
changing  with  the  change  in  the  position  of  the  patient. 

Fig.  10. 


Tympanitic  resonance. 
Ainphoric  respiration. 
Metallic  tinkling.  .  . 
Succussion  sound.  .  . 
Absent  vocal  fremitus. 

Flatness 

Absent  voice.  .  .  . 
Absent  respiration.     . 


Diagram  illustrative  of  the  Physical  Signs  of  Hydro-pneumo-Thorax. 

Auscultation. — Below  the  level  of  the  fluid  there  is  entire 
absence  of  all  the  respiratory  and  vocal  sounds  ;  above  its 
level,  there  is  usually  amphoric  respiration  and  metallic  tink- 
ling. 

The  characteristic  physical  sign  of  this  disease  is  the  suc- 
cussion sound,  which  is  a  metallic,  splashing  sound,  produced 
by  abruptly  shaking  the  chest  while  the  ear  is  resting  on  its 
surface. 


Phthisis  FiiZmonalis. 

The  physical  signs  of  pulmonary  phthisis  correspond  in  a 
great  measure  with  the  extent  and  condition  of  the  tubercular 
deposit.     There  are  three  recognized  stages  in  this  disease. 


72  PHYSICAL  DIAGNOSIS 

First,  The  stage  of  deposit;  Second,  The  stage  of  softening; 
Third,  The  stage  of  excavation. 

We  will  now  consider  the  physical  signs  as  they  present 
themselves  in  each  of  these  stages,  premising  that,  as  a  mle, 
the  deposit  occui's  first  in  the  apex  of  the  lung. 

First  Stage. — Inspection  afibrds  Httle  information,  unless 
the  deposit  is  large  in  amount,  or  is  confined  to  one  apex.  In 
the  latter  case  there  is  diminution  of  expansion  in  the  supra  and 
infra-clavicular  regions  of  the  affected  side,  and  a  noticeable 
flattening  of  the  upper  part  of  the  chest  walls  on  the  same 
side  :  in  the  former  case  an  abnormal  rapidity  of  the  respira- 
tory movements  will  be  observable,  but  the  flattening  which  the 
deposit  occasions  is  rarely  observable. 

Palpation. — By  palpation  you  will  often  detect  deficient  ex- 
pansion in  the  infra-clavicular  region  of  the  affected  side, 
when  it  cannot  be  detected  by  inspection.  There  is  also  a 
sHght  increase  in  the  vocal  fremitus  ;  this  increase,  however, 
is  less  significant  when  it  occurs  on  the  right  side  than  on  the 
left. 

Percussion. — The  difference  of  the  percussion  note  in  the 
infra-clavicular  region  on  the  two  sides,  rather  than  the  quahty 
of  the  sound,  is  important.  K  a  small  amount  of  tubercles 
exist,  and  they  are  superficial,  there  will  be  a  slight  rise  in 
the  pitch  of  the  percussion  sound  on  the  affected  side ;  but  if 
some  emphysematous  lung  intervene  between  the  consohdated 
lung  and  the  chest  walls,  the  percussion  sound  may  be  nor- 
mal, or  extra-resonant,  over  the  affected  portion.  To  detect 
this  last,  the  percussion  sound  must  be  lightly  made,  and  the 
percussion  blow  must  be  du-ected  from  and  not  towards  the 
trachea.  If  doubts  exist,  percussion  should  be  performed  at 
the  end  of  a  full  inspiration,  and  then  at  the  end  of  a  full  expi- 
ration. 

Auscultation. — The  results  of  auscultation  vary.  The  res- 
piratory murmur  in  the  infi-a-clavicular  and  supra-scapular 


PHTHISIS  PULMONALIS. 


73 


regions  may  be  weak  and  almost  suppressed  at  some  points, 
and  exaggerated  at  others.  It  may  also  be  jerking  or  "  cog- 
ged-wheel," in  its  rhythm,  and  rude  or  bronchial  in  its  quaHty. 
The  inspiratory  sound  loses  its  soft,  breezy  character,  and  be- 
comes high-pitched  and  tubular ;  while  the  expiratory  becomes 
higher  pitched  than  the  inspiratory,  and  is  prolonged.  Pro- 
longed expiration,  however,  if  unattended  with  any  alteration 

Fig.  11. 


Ende  respiration.   .    .    .    . 

Slight  dulnesB 

Increased  vocal  fremitus.     . 
Increased  vocal  resonance  . 


Scattered  Tubercular  Deposit  at  the  Apex  of  the  Lung.— DACoefr a. 


in  quahty,  is  insignificant,  or,  if  it  is  low-pitched,  it  furnishes 
no  evidence  of  tubercle.  The  value  of  these  states  of  the 
respiration  corresponds  to  their  position.  If  they  exist  above, 
and  are  imperceptible  below  the  second  interspace,  they  are 
seriously  significant.  The  only  adventitious  sound  belonging 
specially  to  this  stage  of  phthisis  is  the  mucous  clicl%  which  is 
more  frequently  audible  in  the  supra-scapular  fossae  than  in 
front. 

The  auscultatory  signs  of  bronchitis,  pneumonia,  and  dry 
pleurisy  may  be  superadded  to  these,  but  they  cannot, 
strictly  speaking,  be  regarded  as  physical  signs  of  tubercle. 
"When  the  deposit  of  tubercle  is  extensive,  and  includes  bron- 
chial tubes  of  considerable  size,  the  evidences  are  rendered 
more  conclusive  by  the  presence  of  bronchial  respiration,  etc. 
The  heart  sound  over  the  affected  lung  will  also  be  increased 
in  intensity.     Vocal  resonance  is  subject  to  so  many  varia- 


74  PHYSICAL  DIAGNOSIS. 

tions  as  to  render  it  valueless  as  a  basis  of  diagnosis.  Ex- 
aggerated vocal  resonance  at  the  right  apex  can  hardly  be  re- 
garded as  even  suggestive  of  tubercle  ;  at  the  left  apex  it  is  of 
more  importance. 

Second  Stage. — Many  of  the  signs  already  described  as 
characteristic  of  the  first  stage  now  become  more  marked,  and 
new  auscultatory  signs  referable  to  the  stage  of  softening  are 
developed. 

Inspection. — You  will  now  perceive  a  greater  frequency  in 
the  respiratory  acts,  a  more  marked  depression  above  and 
below  the  clavicles,  and  an  increased  deficiency  in  local  ex- 
pansion, especially  during  a  forced  inspiration. 

Percussion  eMcits  a  wider  spread  and  more  intense  dulness, 
and  it  often  assumes  a  wooden  or  tubular  character. 

Auscultation. — The  respiration  grows  more  extensively  and 
markedly  bronchial,  and  moist  crackling  rales  of  a  metallic 
character  are  heard.  When  the  elimination  of  the  softened 
material  commences,  the  rales  become  cavernous  in  character. 
Vocal  resonance  and  vocal  fremitus  are  extremely  variable 
and  cannot  be  relied  upon. 

Third  Stage.— Inspection. — The  signs  obtained  by  inspec- 
tion remain  as  in  the  second  stage,  except  that  the  rapidity  of 
the  respiration  is  increased,  and  the  depression  in  the  infra  and 
supra-clavicular  regions  becomes  marked,  and  there  is  more 
complete  absence  of  the  respiratory  movements  during  the 
respiratory  acts. 

Palpation  is  stiU  unreliable,  although  when  a  cavity  is 
large  and  superficial,  vocal  fremitus  is  increased,  and  some- 
times a  gurghng  fremitus  is  detected. 

Percussion. — The  percussion  sound  varies  according  to 
the  condition  of  the  cavities,  and  the  lung  tissue  surrounding 
them.  If  the  cavity  is  of  small  size  and  surrounded  with  con- 
sohdated  lung  tissue,  the  percussion  sound  will  be  absolutely 
dull  or  tubular  in  quality.     If  a  layer  of  healthy  lung  tissue 


PHTHISIS  PULMONALIS.  75 

intervene  between  the  chest  walls  and  the  cavity,  the  latter 
being  full,  gentle  percussion  will  give  normal  resonance,  while 
forcible  percussion  wiU  elicit  deep-seated  dulness.  Large, 
empty,  superficial  cavities  with  thin,  tense  walls,  yield  an  am- 
phoric, pr  "  cracked-pot "  resonance. 

Auscultation. — If  the  cavity  is  empty  and  communicates 
freely  with  a  bronchial  tube,  and  no  healthy  lung  tissue  lies 
between  it  and  the  chest  walls,  the  respiration  will  be  either 
cavernous  or  amphoric,  as  shown  in  fig,  6 ;  cavernous,  when 
the  cavity  is  of  small  size,  with  flaccid  walls,  so  that  they  col- 
lapse with  expiration,  and  expand  with  inspiration ;  amphoric, 
when  the  cavity  is  large,  and  surrounded  with  consohdated 
lung,  so  that  its  walls  are  tense  and  do  not  collapse  in  ex- 
piration. If  fluid  has  accumulated  in  the  cavity  sufficiently 
to  rise  above  the  opening  into  it,  large  or  smaU  sized  gurgles 
will  be  heard,  as  shown  in  fig.  6 ;  metallic  tinkling  wiU  some- 
times be  heard  over  cavities  of  large  size.  Vocal  resonance 
may  give  us  either  pectoriloquy,  or  be  amphoric,  broncho- 
phonic,  weak,  or  entirely  absent.  SmaU  cavities  partially 
filled  with  fluid  deeply  seated,  do  not  give  rise  to  signs  char- 
acteristic of  cavities,  but  simply  furnish  blowing  respiration 
and  small  sized  gurgles,  which  resemble  very  closely  mucous 
rales. 


HEAET  AID  THOEACIC  AORTA. 


LESSON  IX. 

Topography  of  tlie  Heart  and  Aorta.— Thj/siological  Action 
of  the  Heart. 

The  diagnosis  of  many  cardiac  diseases  rests  upon  our 
knowledge  of  the  relations  of  the  different  compartments  and 
orifices  of  the  heart  to  the  chest  walls.  It  is  therefore  neces- 
sary to  be  familiar  with  this  relationship,  and  with  the  physi- 
ological acts  which  constitute  a  complete  cardiac  pulsation, 
before  we  can  intelligently  study  the  physical  signs  involved 
in  the  diagnosis  of  these  diseases. 

By  referring  to  fig.  1,  the  relations  of  the  heart  to  the  adja- 
cent viscera  will  be  readily  a23preciated. 

In  the  healthy  chest,  the  auricles  are  on  a  line  with  the 
third  costal  cartilages.  The  rujlit  auricle  extends  across  the 
sternum,  a  little  beyond  its  right  border.  The  left  auricle  lies 
deeply  behind  the  pulmonary  artery.  The  middle  portion  of 
this  auricle  corresponds  to  the  cartilage  of  the  third  rib.  The 
o'igM  ventricle  lies  partly  behind  the  sternum,  and  partly  to  the 
left  of  it ;  its  inferior  border  is  on  a  level  with  the  sixth  car- 
tilage. The  left  ventricle  lies  also  for  the  most  part  behind 
and  to  the  left  of  the  sternum,  between  the  third  and  fifth 
intercostal  spaces.  Only  a  narrow  strip  of  the  ventricle  is 
visible  anteriorly.  The  heart,  then,  as  a  whole,  extends  verti- 
cally from  the  second  space  to  the  sixth  costal  cartilage,  and 
transversely  fi^om  about  half  an  inch  to  the  right  of  the  ster- 
num to  within  half  an  inch  of  the  left  nipple.  Posteriorly,  the 
base  lies  opposite  the  sixth  and  seventh  dorsal  vertebrae.  The 
entire  left  ventricle,  the  greater  part  of  the  left  auricle,  and  a 


80  PHYSICAL  DIAGNOSIS. 

large  portion  of  the  apex  of  the  right  ventricle,  he  to  the  left 
of  the  sternum.  Behind  the  sternum  He  a  greater  portion  of 
the  right  auricle  and  ventricle,  and  a  small  portion  of  the  left. 
To  the  right  of  the  sternum  lie  a  portion  of  the  right  auricle, 
and  the  upper  portion  of  the  right  ventricle.  The  whole  of 
the  anterior  surface  of  the  heart  is  overlapped  by  the  lungs, 
except  a  triangular  space  corresponding  to  the  lower  portion 
of  the  right  ventricle. 

The  Surface  Measurements  of  the  heart  are  as  follows : 
Ventricle  measurement  from  the  second  interspace  to  the  fifth 
interspace,  five  inches ;  from  the  median  line  to  the  left,  on 
the  third  rib,  two  and  a  haK  to  three  inches ;  on  the  fourth 
rib,  from  three  and  a  haK  to  four  inches  ;  in  the  fifth  inter- 
space, from  three  to  three  and  a  haK  inches. 

JRelative  Position  of  the  Valves. 

The  Tricuspid  Valve  lies  behind  the  middle  of  the  sternum, 
on  a  hne  with  the  articulation  of  the  cartilages  of  the  fourth 
ribs  with  the  sternum. 

The  Mitral  Valve  hes  behind  the  cartilage  of  the  fourth . 
left  rib  near  the  sternum. 

The  Aortic  Valves  he  behind  the  sternum,  a  little  below 
the  junction  of  the  cartilages  of  the  third  ribs  with  the  ster- 
mun,  and  near  its  left  edge. 

The  Pulmonary  Valves  He  behind  the  junction  of  the  third 
left  rib  with  the  sternum.  A  circle  of  an  inch  in  diameter 
with  its  centre  at  the  left  edge  of  the  sternum,  a  Httle  below 
the  junction  of  the  third  rib  with  the  sternum,  wiU  include  a 
portion  of  aU  these  four  sets  of  valves. 

The  Aorta  arises  from  the  left  ventricle  behind  the  sternum, 
opposite  the  tldrd  intercostal  space,  and  passes  from  left  to 
right ;  the  ascending  portion  of  the  arch  comes  to  the  right  of 
the  sternum  between  the  cartilages  of  the  second  and  thu'd 
ribs ;  in  this  part  of  its  course  it  is  within  the  pericardial  sac ; 


ACTION  OF  THE  HEART.  gj 

thence  the  transverse  portion  of  the  arch  crosses  the  trachea 
just  above  its  bifurcation,  at  the  centre  of  the  first  bone  of  the 
sternum,  on  a  hne  with  the  lower  margin  of  the  articulation  of 
the  cartilages  of  the  first  ribs  with  the  sternum ;  thence  the 
descending  portion  passes  backwards  and  downwards  towards 
the  left  side  of  the  third  dorsal  vertebra,  and  rests  ultimately 
upon  the  left  side  of  the  bodies  of  the  fifth  and  sixth  dorsal 
vertebrae.  The  arch  of  the  aorta  approaches  most  closely  to 
the  chest  walls,  at  the  point  where  the  arteria  innominata  is 
given  off ;  that  is,  on  a  line  with  the  junction  of  the  cartilage 
of  the  second  right  rib  with  the  sternum. 

The  Pulmonary  Artery  arises  from  the  right  ventricle  to 
the  left  and  behind  the  sternum,  on  a  line  with  the  junction 
of  the  cartilages  of  the  third  ribs  with  the  sternum ;  it  as- 
cends upwards  and  backwards  about  two  inches,  when  it  bi- 
furcates opposite  the  second  costal  cartilage. 

The  Pericardial  Sac  encloses  the  heart,  and  may  be  repre- 
sented as  a  cone,  extending  from  the  second  to  the  seventh 
left  costal  cartilage.  The  base  of  the  cone  rests  on  and  is 
attached  to  the  diaphragm,  and  the  apex  embraces  the  lower 
two  inches  of  the  great  vessels.  The  larger  portion  of  the  sac 
lies  to  the  left  of  the  median  line,  and  is  farther  from  the  an- 
terior chest  walls  superiorly  than  it  is  inferiorly. 

Physiological  Action  of  the  Seart, 

The  actions  which  constitute  a  complete  cardiac  pulsation 
are  the  contraction,  dilatation,  and  rest  of  each  of  its  cavities. 
These  acts  are  attended  by  alteration  in  the  form,  size,  axis, 
and  position  of  the  heart.  The  contraction  of  the  ventricles, 
or  their  systole,  as  it  is  termed,  constitutes  the  active  state  of 
the  heart ;  as  soon  as  this  ceases,  the  muscular  tissue  relaxes, 
the  cavities  enlarge,  and  the  ventricles  are  said  to  dilate,  this 
process  constituting  what  is  termed  the  diastole  of  the  heart. 


82 


PHYSICAL  DIAGNOSIS. 


Auricular  Systole. — The  heart's  action  begins  witli  the 
contraction  or  systole  of  the  auricles.  By  it  a  small  additional 
quantity  of  blood  is  propelled  into  the  ventricles ;  but  its  con- 
traction is  too  slight,  either  to  empty  the  auricles  or  to  cause 
the  dilatation  of  the  ventricles.  Its  duration  is  about  the 
eighth  part  of  an  entire  beat  of  the  heart,  the  mitral  and  tri- 
cuspid valves  being  open,  while  the  aortic  and  pulmonary 
valves  are  closed,  as  shown  in  the  diagram  fig.  12. 

Fig.  12. 


Diagram,  showing  the  Changes  that  occur  in  the  Valves  and  Cavities  of  One  Side  of  the  Heart 
during  a  Cardiac  Pulsation. 

Auricular  Diastole. — The  dilatation  or  diastole  of  the  auri- 
cles is  a  passive  movement ;  these  cavities  are  gradually  dis- 
tended by  the  blood  which  enters  from  the  venae  cavse  and 
pulmonary  veins,  the  mitral  and  tricuspid  valves  being  closed, 
and  the  aortic  and  pulmonary  being  open,  as  is  shown  in  the 
diagram  (fig.  12).  It  continues  from  the  termination  of  one 
auricular  systole  to  the  commencement  of  the  next. 

Ventricular  Systole. — The  contraction  or  systole  of  the 
ventricles  succeeds  immediately  upon  that  of  the  auricles  ;  or, 
in  other  words,  the  sudden  distention  of  the  ventricles  by  the 
blood  propelled  into  them,  during  the  systole  of  the  auricles, 
is  rapidly  followed  by  the  contraction  of  the  ventricles.   During 


PERIOD  OF  REPOSE.  83 

their  contraction  the  vertical  diameter  of  the  heart  is  dimin- 
ished, the  ajpex  is  approximated  to  the  base,  and  describes  a 
spiral  motion  from  right  to  left,  and  from  behind  forwards, 
coming  in  contact  with  the  walls  of  the  thorax  between  the 
cartUages  of  the  fifth  and  sixth  ribs  on  the  left  side,  where  the 
impulse  of  the  heart  is  felt.  With  the  ventricular  systole  the 
blood  is  propelled  with  considerable  force  from  the  ventricles 
into  the  aorta  and  pulmonary  arteries.  The  mitral  and  tricus- 
pid valves  are  closed,  and  the  aortic  and  pulmonary  valves 
are  open,  as  is  shown  in  the  diagram  (fig.  12).  It  occupies 
about  one-half  of  the  entire  beat  of  the  heart. 

Ventricular  Diastole. — The  dilatation  or  diastole  of  the 
ventricles  immediately  succeeds  their  contraction,  during 
which  the  blood  flows  in  full  stream  from  the  auricles  into 
the  ventricles  ;  the  mitral  and  tricuspid  valves  are  open,  and 
the  aortic  and  pulmonary  are  closed  (as  shown  in  fig.  12)  ;  the 
heart  becomes  elongated,  and  it  assumes  the  shape  and  posi- 
tion which  it  had  before  the  systole.  The  duration  of  the 
diastole  occupies  about  one-fourth  of  the  entire  beat  of  the 
heart ;  the  second  sound  of  the  heart  is  synchronous  with  it. 

Period  of  Repose. — From  the  termination  of  the  diastole 
of  the  ventricles,  to  the  commencement  of  the  auricular  sys- 
tole, the  ventricles  are  in  a  state  of  perfect  rest,  their  cavities 
remaining  full  but  not  distended ;  the  duration  of  this  period 
is  less  than  one-fourth  the  entire  beat  of  the  heart.  As  soon 
as  the  auricles  become  distended,  they  contract,  and  another 
heart  action  commences.  If  the  duration  of  all  these  move- 
ments, from  the  commencement  of  one  pidse  to  the  com- 
mencement of  another,  be  divided  into  five  equal  parts,  two- 
fifths  will  be  occupied  by  the  contraction  of  the  ventricles ; 
one-fifth  by  dilatation  of  the  ventricles,  and  the  remaining 
two-fifths  by  the  period  of  rest  and  the  contraction  of  the 
auricles. 

In  order  that  you  may  readily  appreciate  the  whole  series 


8i 


PHYSICAL  DIAGNOSIS. 


and  sequence  of  these  elements  in  the  heart's  action,  I  will 
employ  the  diagram  of  Prof.  W.  T.  Gairdner. 

It  consists  of  two  circles.  The  physiological  action  of  the 
heart,  apart  from  its  external  manifestations,  is  indicated  by 
the  inner  circle  and  its  divisions ;  the  external  rim  is  occupied 
by  marks  corresponding  to  the  sounds;  and  the  different 


Foot 


2'L'SoaND 


Diagram  showing  the  Pkgaiological  Action  of  the  Heart  in  C<mnection  toUh  its  External 
Manifestations-— Gajsdhsr. 

pulses  or  impulses  are  portrayed  by  lines  projecting  from  the 
circumference  of  the  outer  circle.  The  physiological  facts 
which  constitute  a  cardiac  pulsation  are  thus  apparent.  "  Be- 
ginning with  the  contraction  of  the  ffuricles,  then  that  of  the 
ventricles,  then  the  rapid  dilatation  of  the  ventricles,  and  then 
the  pause,  succeeded  by  the  contraction  of  the  auricles  again." 
"It  is  apparent  also  that  in  this  succession  of  action,  the  phe- 
nomena which  we  can  appreciate  externally  are  a  little  later 
than  the  real  commencement  of  the  heart's  action ;  they  do  not 


RHYTHM  OF  THE  HEART.  85 

correspond  to  the  very  first  beginniiig  of  movement,  for,  before 
there  is  either  sound  or  impulse,  the  contraction  of  the  auricles 
has  already  taken  place ;  and  when  the  impulse  is  perceptible  in 
the  carotid,  the  contraction  of  the  ventricles  has  commenced, 
and  by  the  time  it  is  perceptible  in  the  foot,  it  is  almost  com- 
plete. During  the  diastole  of  the  ventricles  and  the  period  of 
rest  aU  external  manifestations  are  lost."  This  series  of  actions 
constitutes  what  is  called  the  rhythm  of  the  heart. 

There  are  certain  difficulties  that  are  apt  to  occur  in  esti- 
mating the  normal  rhythm  of  the  heart.  The  entire  period  of 
the  heart's  action  may  be  divided  into  a  period  of  motion  and 
one  of  rest ;  the  former  is  subdivided  into  three  distinct  stages 
or  periods  indicated  in  the  diagram  (fig.  13).  Now,  it  is  im- 
portant to  observe  that  when  the  heart's  pulsations  follow  one 
another  with  great  rapidity,  the  period  of  rest  is  reduced  to  a 
minimum;  and  when,  on  the  contrary,  the  heart's  action  is 
slow,  the  period  of  rest  is  much  lengthened,  in  proportion  to 
the  period  of  motion;  the  consequence  of  this  is,  that  the 
normal  sounds  which  occur  during  the  contraction  and  dilata- 
tion of  the  ventricles  change  their  relation  to  one  another 
according  as  the  pulsations  are  in  rapid  succession  or  the 
contrary.  In  the  former  case  the  interval,  between  the  second 
and  first  sound  (which  includes  the  period  of  rest,  and  the 
contraction  of  the  auricles)  is  very  short ;  in  the  latter,  it  is 
very  long.  Hence  the  altered  relation  which  is  indicated  to 
the  eye  in  fig.  14,  and  which  is  very  embarrassing  to  the  be- 
ginner. 

The  larger  circumference  of  each  successive  circle  indicates 
the  lengthening  of  the  pause  ;  and,  accordingly,  you  have  the 
interval  between  the  first  and  second  sounds  occupying  a  less 
and  less  arc  of  the  circle,  as  the  heart's  action  gets  slower, 
while  the  interval  between  the  second  and  first  sounds  is  cor- 
respondingly lengthened.  In  the  first  and  smallest  circle,  in- 
dicating the  most  rapid  action,  the  two  intervals  are  nearly 


86 


PHYSICAL  DIAGNOSIS. 


Fig.  14. 


alike,  and  each  occupies  about  one-half  the  circumference  ;  in 
the  last  or  largest  circle  (indicating  very 
slow  action),  the  interval  between  the 
second  and  first  sounds  is  four  times  as 
long  as  that  between  the  first  and  sec- 
ond. Hence  it  is  that,  when  the  heart 
is  acting  rapidly,  it  is  difficult  to  distin- 
guish the  first  sound  from  the  second, 
and  vice  versa;  while  with  the  slowly 
acting  heart  this  difficulty  does  not 
occur.  Attention  to  these  varieties — 
physiological  varieties  they  may  be 
called — ^in  the  rhythm  of  the  soimds  is 
of  very  great  importance  in  determining 
the  attributes  of  a  cardiac  murmur  ;  for 
the  first  step  in  the  inquiry  is  to  deter- 
mine which  is  the  second  sound  and 
which  is  the  first ;  and  this,  as  I  have 
said,  is  sometimes  not  quite  an  easy 
matter.  Generally  speaking,  and  in  all 
cases  when  the  action  is  slow  and  regu- 
lar, there  is  no  difficulty ;  you  have  only  to  remember  that 
the  longer  interval  is  between  the  second  and  first  sounds,  and 
the  shorter  interval  between  the  first  and  second;  but  when  the 
action  is  rapid  or  irregular,  and  when  the  first  sound  is  indis- 
tinct at  the  apex,  or  cannot  be  identified  with  the  apex  beat, 
and  also  when  the  second  sound  is  indistinct,  or  when  it  is 
audible  only  at  the  base,  the  first  sound  being  audible  only  at 
the  apex,  as  sometimes  happens,  the  difficulty  of  recognition 
of  the  two  sounds  is  very  considerable. 


LESSON    X. 

Methods  of  Cardiac    'Pfij'sical  JSJxamination. 

The  metliods  of  physical  examination  of  the  heart  include 
inspection,  palpation,  mensuration,  percussion,  and  auscultaticm. 

By  Inspection  you  note  the  exact  point  of  the  heart's  im- 
pulse where  it  strikes  the  walls  of  the  chest,  and  also  whether 
there  is  any  unusual  pulsation,  or  any  change  in  the  form  of 
the  cardiac  region.  In  a  perfectly  normal  chest,  the  infra- 
mammary  regions  on  either  side  are  very  nearly  symmetrical ; 
but  in  disease,  the  prsecordial  region  may  either  be  depressed, 
or  on  the  contrary  arched  forward,  and  the  intercostal  spaces 
be  widened.  The  most  important  information  furnished  by 
inspection  relates  to  the  cardiac  impulse.  This,  in  the  major- 
ity of  persons,  is  visible  only  in  the  fifth  interspace,  midway 
between  the  left  nipple  and  the  sternum,  and  its  area  does  not 
exceed  a  square  inch.  You  will  generally  find  it  most  distinct 
in  thin  persons,  while  in  fleshy  individuals  it  is  sometimes 
scarcely  discernible ;  and  you  will  also  find  that  it  may  be 
modified  by  position,  by  distension  of  the  subjacent  stomach, 
and  by  the  movements  of  respiration.  Thus  during  a  full  in- 
spiration you  may  note  the  impulse  down  in  the  epigastrium, 
and  then  during  a  forced  expiration  see  it  elevated  and  more 
diffused. 

In  disease  you  may  find  the  impulse  altered  as  respects  its 
position,  its  area,  or  its  force.  Thus  it  is  tilted  upwards  and 
outwards  by  enlargement  of  the  left  lobe  of  the  liver ;  or  it 
may  be  crowded  over  to  the  right  side  and  downwards  by 
simple  pleuritic  effusion  or  emphysema,  so  that  I  have  seen  it 


88  PHYSICAL  DIAGNOSIS. 

beating  even  externally  to  the  right  nipple ;  it  may  also  be 
forced  upwards  by  pericardial  effusion,  or  downwards  and  to 
the  left  in  cardiac  hypertrophy.  Not  unfrequently  in  cases  of 
pericardial  agglutination,  or  dilatation  of  the  ventricles,  an 
undulating  impulse  will  be  visible. 

Palpation. — This  is  of  much  greater  clinical  importance 
than  inspection.  By  it  we  determine  the  force  of  the  cardiac 
pulsation;  the  frequency  or  slowness  of  the  heart's  action; 
and  the  regularity  or  irregularity  of  its  movements.  By  it 
also  we  detect  the  presence  of  the  friction  fremitus,  and  what 
is  termed  the  "purring  tremor^ 

The  force  of  the  cardiac  impulse  may  be  diminished  or  in- 
creased. 

Diminution  of  the  Impulse  may  depend  either  upon 
feebleness  of  the  action  of  the  heart  in  consequence  of  de- 
generation of  its  tissues,  and  in  cases  of  prostration  of  the 
whole  system  as  in  collapse  ;  or  upon  the  apex  of  the  organ 
being  prevented  from  impinging  against  the  walls  of  the  chest 
with  its  customary  force,  as  happens  in  disease  of  the  lungs 
and  pericardium. 

Increase  of  the  Impulse. — In  the  majority  of  instances 
this  is  caused  by  hypertrophy  of  the  walls  of  the  left  ventricle, 
and  a  slow  progressive  impulse  can  be  produced  by  no  other 
cause.  In  such  cases  the  area  over  which  the  cardiac  impulse 
can  be  felt  is  much  increased.  In  the  early  stage  of  endocar- 
ditis, and  of  pericarditis,  and  in  palpitations  from  functional 
disorders,  the  impulse  is  slightly  increased. 

Change  in  the  Situation  of  the  Impulse. — A  change  in  the 
situation  of  the  cardiac  impulse  may  occur  as  the  result  either 
of  hypertrophy,  or  of  displacement  of  the  heart  from  disease 
of  the  lungs  or  pleura. 

The  frequency  and  regularity  of  the  heart's  action  is  of 
great  importance  in  the  diagnosis  of  cardiac  disease ;  and  it 
can  often  be  most  accurately  determined  by  palpation. 


PERCUSSION. 


89 


The  Purring  Thrill  (the  ''fremissement  cataire  "  of  Laennec) 
is  a  peculiar  vibratory  sensation  perceptible  on  making  pres- 
sure at  the  prsecordium.  In  some  the  pressure  need  be  but 
shght,  while  in  others  it  should  be  firm.  It  may  also  be  com- 
municated by  the  large  arteries,  etc. 

Percussion. — By  percussion  we  aim  to  make  out  the  exact 
outline  of  the  heart  itself,  and  of  its  investing  membrane,  to 
determine  whether  it  exceeds  its  normal  area  ;  and  to  do  this 
well,  you  will  find  both  care  and  practice  requisite.  In  per- 
forming cardiac  percussion,  the  patient  should  be  in  a  recum- 
bent posture,  and  you  need  tap  but  lightly  over  the  part 
where  the  heart  is  not  covered  by  lung  tissue,  to  obtain  a  flat 
sound.  Where,  however,  the  lungs  overlap  the  organ,  you 
must  percuss  more  forcibly  to  eHcit  cardiac  dulness,  and  this 
soimd  wiQ  of  necessity  have  more  or  less  of  a  pulmonary  qual- 
ity. We  have,  therefore,  two  degrees  of  cardiac  dulness, — 
the  superficial  and  the  deep-seated.  In  health  the  area  of  the 
superficial  dulness  does  not  exceed  two  inches  in  any  direction ; 
it  is  triangular  in  form,  with  the  apex  immediately  below  the 
junction  of  the  left  third  rib  with  the  sternum,  whUe  the  base 
is  on  a  hne  with  the  cartilage  of  the  sixth  rib.  The  area  of 
the  deep-seated  dulness  ia  health  extends  transversely  from 
the  left  nipple  to  half  an  inch  to  the  right  of  the  sternum,  and 
vertically  from  the  second  to  the  sixth  interspace. 

The  area  of  the  heart's  superficial  dulness  may  be  increased 
or  diminished ;  increased,  when  the  ventricles  are  hypertro- 
phied,  or  when  their  cavities  are  dilated,  and  also  when  the 
pericardium  contains  fluid ;  diminished,  at  the  end  of  a  full 
inspiration,  and  in  pulmonary  emphysema  from  its  inducing  a 
general  distension  of  the  air  cells.  The  area  of  the  deep- 
seated  dulness  is  increased  by  enlargement  of  the  heart, 
whether  this  be  due  to  ventricular  dilatation,  or  to  hyper- 
trophy of  its  muscular  parietes  ;  and  it  is  apparently  increased 
by  consohdation  of  the  anterior  border  of  the  investing  lung, 


90  PHYSICAL  DIAGNOSIS. 

and  also  by  fluid  in  the  left  pleural  cavity.  We  are  also  often 
mucli  assisted  in  determining  the  limits  of  the  deep-seated 
dulness  in  certain  cases  by  auscultatory  percussion. 

Auscultation. — For  reasons  already  stated  I  prefer  mediate 
to  immediate  auscultation  in  examining  the  heart,  and  in 
practising  it  you  will  find  of  service  the  following  simple  rules : 

1.  The  posture  of  the  patient  should  be  recumbent  when 
you  begin  your  examination.  Then,  having  carefully  elicited 
aU  the  auscultatory  symptoms  which  this  posture  affords,  re- 
peat your  examination  with  him  sitting  or  standing,  and  note 
whether  any  variations  in  the  sounds  heard  have  occurred 
from  the  change  in  his  position. 

2.  You  should  first  listen  to  the  heart  sounds  while  the 
patient  is  breathing  naturally;  having  done  so,  then  direct 
him  to  hold  his  breath  for  a  moment ;  and  finally  tell  him  to 
take  three  or  four  forced  inspirations.  These  various  means 
are  often  aU  required  before  we  can  correctly  discriminate 
between  the  different  signs  in  cardiac  auscultation. 

3.  You  should  not  confine  your  examination  to  the  prsecor- 
dial  region  alone,  but  should  explore  the  whole  thoracic  cavity 
and  endeavor  to  locahze  the  points  at  which  the  heart  sounds, 
both  normal  and  abnormal,  are  heard  with  the  greatest  inten- 
sity. To  this  end  proceed  in  your  examination  from  below 
upwards,  and  from  left  to  right. 

As  in  the  case  of  pulmonary  auscultation,  so  here,  the  nor- 
mal characters  must  be  the  starting-point  or  standard  by 
which  every  system  in  cardiac  auscultation  is  to  be  compared. 
You  cannot,  therefore,  pay  too  much  attention  towards  ac- 
quiring a  familiarity  with  the  elements  of  the  heart  sounds  in 
health.  These  elements  are  as  follows  :  When  the  ear  or 
stethoscope  is  appHed  to  the  praecordial  region,  two  successive 
sounds  are  heard,  followed  by  an  interval  of  silence,  which 
therefore  does  not  intervene  between  the  first  and  second,  but 
between  the  second  and  first.    The  first  sound  is  softer,  lower 


MECHANISM  OF  HEART  SOUNDS.  91 

in  pitch,  and  more  prolonged  than  the  second ;  as  has  already 
been  shown  in  fig,  13,  it  coincides  with  the  systole  of  the  ven- 
tricles and  with  the  apex  beat ;  it  immediately  precedes  the 
radial  pulse,  and  has  its  maximum  of  intensity  in  the  fifth  in- 
terspace, a  httle  to  the  right  of  the  left  nipple.  The  second 
sound  is  sharper,  or  higher  pitched,  shorter  and  more  superfi- 
cial than  the  first.  It  is  synchronous  with  the  diastole  of  the 
ventricles,  occurs  after  the  pulsation  of  the  arteries,  and  has 
its  maximum  of  intensity  at  the  jimction  of  the  third  left  rib 
with  the  sternum. 

The  period  of  silence  immediately  following  the  second 
sound  varies  in  length  with  the  rapidity  of  the  heart's  action. 
The  order  and  duration  of  the  respective  periods  of  the  soimds, 
and  the  silence,  you  will  be  able  to  appreciate  best  by  refer- 
ring to  diagram  Nos.  13  and  14. 

The  intensity  of  the  heart  sounds  varies  m  health  according 
to  the  force  of  the  heart's  action,  or  according  to  the  confor- 
mation of  the  chest,  or  according  to  individual  idiosyncrasies. 
These  sounds  are  less  intense  in  fleshy  or  muscular  persons 
with  capacious  chests,  than  in  thin,  narrow-chested,  and  nerv- 
ous individuals. 

The  extent  of  surface  over  which  the  heart  sounds  are  heard 
varies  mth  the  adaptation  of  the  adjacent  organs  for  transmit- 
ting sounds.  Generally  speaking,  the  sounds  produced  on  the 
right  side  of  the  heart  are  more  audible  on  the  right  side  of 
the  prsecordial  region ;  while  those  produced  on  the  left  are 
more  pronounced  on  their  corresponding  side. 

Mechanism  of  the  Heart  Sounds. — There  has  been  much 
dijBference  of  opinion  on  this  subject.  My  own  opinion  is  this : 
that  the  first  sound  is  produced  by  the  closiu'e  of  the  mitral 
and  tricuspid  valves  ;  also  that  it  has  in  addition  elements  in 
its  production  which  are  not  valvular;  namely,  sound  from 
the  impulse  of  the  heart's  apex  against  the  thoracic  walls, 
from  the  contraction  of  the  ventricles,  and,  lastly,  fi-om  the 


92  PHYSICAL  DIAGNOSIS. 

friction  of  the  blood  against  tlie  walls  of  the  ventricles,  and 
against  the  ventricular  surface  of  the  valves.  Some  eminent 
authorities,  however,  regard  the  closure  of  the  above-mentioned 
valves  as  the  one  and  only  cause  of  this  sound.  As  to  the 
second  sound,  all  are  agreed  to  its  proceeding  from  the  sudden 
closure  and  tension  of  the  aortic  and  pulmonary  valves,  by 
the  reflux  of  the  blood  on  them  during  the  diastole  of  the 
heart. 

Pathological  Modifications  of  the  Normal  Sounds. — 
In  disease,  the  normal  sounds  of  the  heart  present  various 
definite  alterations  as  regards  their  intensity,  quahty,  pitch, 
seat,  and  rhythm ;  and  they  may  also  be  accompanied,  pre- 
ceded, or  followed  by  adventitious  sounds  or  murmurs. 

An  iruirease  of  intensity  may  be  noted  in  cases  of  hyper- 
trophy and  dilatation  of  the  ventricles ;  in  cases  also  of 
nervous  irritability  of  the  heart,  or  where  there  is  consoKda- 
tion  of  the  adjacent  lung  tissue.  A  diminution  in  intensity 
may  be  found  depending  either  upon  dilatation  of  the  ventri- 
cles without  hypertrophy  of  their  walls ;  or  upon  fatty  degen- 
eration of  the  muscular  tissue  of  the  heart ;  or  on  softening 
of  the  same,  as  ia  typhus  and  typhoid  fevers  ;  or  it  may  be 
owing  to  a  mufaing  of  the  heart  sounds  by  pericardial  effusion, 
or  by  emphysematous  'distension  of  the  anterior  border  of  the 
lung. 

Alterations  in  Quality  and  Pitch.— The  heart  sounds  in 
disease  may  become  dull  and  low-pitched,  or  sharp  and  high- 
pitched.  The  first  sound  is  dull,  muffled,  and  low-pitched, 
when  hypertrophy  is  conioined  with  a  thickened  condition  of 
the  aiu'iculo-ventricular  valves.  On  the  other  hand,  where  the 
ventricular  walls  are  thin,  and  the  valves  natural,  the  first 
sound  becomes  sharp  and  clicking  in  character,  and  the  pitch 
is  raised.  The  second  sound  is  rendered  dull  and  low-pitched, 
by  diminished  elasticity  of  the  arterial  walls,  and  by  thicken- 
ing of  the  aortic  valves,  without  regurgitation.     Sometimes-the 


MODIFICATIONS  OF  NORMAL  SOUNDS.  93 

heart  sounds  liave  a  metallic  or  tinkling  quality  which  depends 
either  upon  an  irritable  action  of  the  heart,  or  on  a  gaseous 
distension  of  the  stomach. 

Alterations  in  Seat.— This  refers  to  the  points  of  the 
maximum  intensity  of  the  respective  sounds,  which  may  be 
displaced,  1st,  upwards  by  certain  changes  in  the  abdominal 
viscera ;  or,  2d,  downwards,  by  tumors  in  the  mediastinum,  and 
by  hypertrophy  with  dilatation  of  the  auricles ;  and  lastly 
laterally,  by  the  accimaulation  of  au-  or  fluid  in  the  pleural 
cavities.  Malformations  of  the  thorax  may  likewise  displace 
them  in  different  directions. 

Alterations  in  Rhythm. — It  not  unfrequently  happens  that 
a  distinct  intermission  occurs  in  the  heart's  action.  After  a 
certain  number  of  regular  beats,  a  sudden  pause  or  silence 
occurs;  the  heart's  action  seems  to  be  suspended  for  an 
instant,  and  then  to  go  on  regularly.  This  intermission  is 
often  observed  in  individuals  who  are  in  perfect  health.  It 
also  occurs  in  diseased  states  of  the  valves  or  orifices  of  the 
heart.  It  is  difficult  to  explain  its  cause,  and  it  has  no  pre- 
cise pathological  significance. 

Irregularity  in  the  Heart  Sounds,  however,  constitutes 
another  and  different  alteration  iu  rhythm.  The  sounds  be- 
come confused  and  tumultuous ;  they  are  alternately  loud  and 
feeble  ;  at  one  time  slow  for  two  or  three  beats,  and  then  they 
follow  each  other  in  rapid  succession.  When  the  irregularity 
is  permanent,  it  is  almost 'positive  evidence  of  organic  disease 
of  the  heart ;  the  most  frequent  form  being  contraction  of 
the  mitral  valves. 

One  or  both  of  the  heart  sounds,  as  well  as  the  period  of 
rest,  may  be  j)rolonged  or  shortened.  In  hypertrophy  of  the 
ventricular  walls  the  first  sound  is  prolonged.  In  dilatation 
of  the  cavities  of  the  ventricles  it  is  shortened.  The  first 
sound  is  also  prolonged  when  the  two  surfaces  of  the  pericar- 
dium are  adherent.     An  obstacle  to  the  flow  of  the  blood  into 


94  PHYSICAL  DIAGNOSIS. 

the  ventricles  prolongs  the  period  of  repose.  Another  altera- 
tion in  the  rhythm  of  the  heart  sounds  is  named  reduplication. 
Each  systolic  sound  may  be  repeated  twice  for  one  diastolic  ; 
or  the  diastolic  may  occur  twice  for  one  systolic.  Sometimes 
only  one  sound  is  audible. 

The  essential  cause  of  the  various  reduplications  seems  to 
be  a  want  of  synchronism  between  the  action  of  the  two  sides 
of  the  heart,  but  they  are  of  slight  clinical  importance. 


LESSON    XI. 

iibnormal  Sounds  of  the  Heart. 

Pericardial  and  Endocardial  Murmurs, 

The  term  murmurs  has  been  applied  to  those  adventitious 
sounds  which  accompany  or  replace  the  normal  sounds  of  the 
heart,  and  which  are  not  heard  in  health.  Their  seat  may  be 
either  within  the  heart ,  at  the  orifices  of  the  ventricles,  when 
they  are  called  endocardial  or  valvular  murmurs ;  or  they  may 
be  external  and  in  the  pericardium,  when  they  are  termed  exo- 
cardial  or  pericardial  friction  sounds. 

Pericardial  Friction  Sounds. — The  pericardium  is  a  serous 
membrane  investing  the  heart,  as  the  pleura  invests  the  ad- 
jacent lung  ;  and  therefore  when  it  is  inflamed  we  have  exactly 
analogous  results  with  those  which  we  described  as  appertain- 
ing to  pleurisy ;  namely,  first  dryness,  and  then  plastic  and 
serous  effusion,  with  the  different  friction  sounds  which  are 
caused  by  the  rubbing  of  the  roughened  surfaces  of  the 
opposed  membrane  upon  one  another  during  the  movements 
of  the  heart.  This  similarity  sometimes  makes  it  a  nice  point 
in  diagnosis  to  distinguish  a  pericarditis  from  a  pleuritis,  but 
the  determining  consideration  will  be,  that  when  it  appertains 
to  the  heart,  it  is  limited  to  the  prsecordial  space,  or  at  least 
that  it  is  synchronous  with  the  cardiac,  and  not  with  the  respi- 
ratory movements. 

The  different  forms  of  the  pericardial  friction  sounds  have 
been  named,  like  those  in  pleuritis,  grazing,  rubbing,  creaking, 
rasping,  etc.     Clinical  experience,  however,  does  not  always 


96  PHYSICAL  DIAGNOSIS. 

show  any  definite  connection  between  the  state  of  the  serous 
surface  and  the  quality  of  a  friction  sound.  The  grazing 
variety  appertains  to  the  initial  stage  of  the  inflammation ; 
the  other  varieties  occur  after  the  plastic  effusion,  and  while 
it  is  undergoing  organization.  These  sounds  vary  in  intensity, 
from  the  slight  rusthng  which  can  be  heard  only  by  close  at- 
tention, to  a  loud  rasping  sound  audible  before  your  ear  is 
appHed  to  the  chest.  As  a  rule,  they  become  more  distinct 
during  expiration  than  inspiration,  and  while  the  patient  is 
sitting,  rather  than  while  recumbent,  owing  to  the  greater  ap- 
proximation of  the  pericardium  to  the  chest  wall  during  these 
states. 

Pericardial  friction  sounds  may  be  single  or  double,  that  is, 
accompanying  both  the  systolic  and  the  diastolic  movements,  or 
either  one  singly.  They  may  accompany  the  valvular  sounds, 
or  be  independent  of  them ;  and  they  always  convey  the  im- 
pression of  being  superficial  in  comparison  with  the  endocar- 
dial murmurs.  They  are  generally  restricted  to  the  pericar- 
dial space,  the  point  of  maximum  intensity  being  usually  at 
the  junction  of  the  fourth  rib  with  the  sternum  ;  and  they  do 
not  often  last  long,  disappearing  frequently  after  a  few  hours, 
or  at  most  in  a  few  days. 

A  pericardial  murmur  is  distinguished  from  an  endocardial 
by  its  rubbing  quahty,  by  its  superficial  character,  and  by  its 
Tbot  being  transmitted  beyond  the  limits  of  the  heart,  either  along 
the  arteries  or  round  the  left  side  to  the  back.  It  may  also  be 
distinguished  from  a  valvular  murmur  by  its  intensity  varying 
with  a  change  in  the  position  of  the  patient,  and  by  its  inde- 
pendence of  the  heart  sounds. 

Endocardial  or   Valvular  Murmurs, 

In  endocardial  murmurs,  the  elements  of  quality  and  inten- 
sity hold  but  a  subordinate  place  as  regards  either  diagnosis 
or  prognosis.     The  same  murmur  may  be  at  different  times, 


MURMURS. 


97 


blowing,  grating,  rubbing,  or  musical,  In  cbaracter,  without 
its  significance  altering  in  tlie  least  through  all  these  changes 
in  its  quality.  "  The  mere  fact  that  a  murmur  exists,  and 
has  a  certain  acoustic  quality,  tells  very  little  as  regard? 
the  true  character  of  a  case."*  Practically  speaking,  endo- 
cardial murmurs  may  be  regarded  as  "audible  announce- 
ments "  that  something  has  occurred  to  roughen  the  surfaces 
of  the  endocardium,  or  to  constrict  the  orifices  of  the  heart,  or 
to  render  the  valves  insufficient,  so  that  they  allow  the  blood 
to  regurgitate,  or  to  diminish  the  elasticity  of  the  great 
vessels,  or  finally,  that  some  change  has  taken  place  in  the 
natural  constituents  of  the  blood  itseK. 

Having  ascertained  the  existence  of  a  cardiac  murmur,  the 
first  question  then  is,  What  is  its  pathological  significance,  or 
in  what  way  has  it  been  produced  ?  To  determine  this,  it  is 
necessary  to  observe  particularly  two  points :  1st,  The 
rhythm ;  and,  2d,  The  seat  of  the  murmur. 

The  Rhythm  ©f  a  Murmur. — Under  this  head  we  ascertain 
the  relation  of  a  murmur  to  the  difi'erent  physiological  acts 
which  constitute  a  complete  cardiac  pulsation.  We  define  the 
murmur  as  occurring  during  either  portion  of  the  heart's 
action,  or  during  the  rest  which  intervenes  between  the 
periods  of  activity.  To  do  this,  we  note  carefully  its  relation 
to  the  normal  sounds,  to  the  impulse,  and  to  all  the  other 
appreciable  phenomena  which  attend  upon  the  heart's  action. 
By  referring  to  fig.  13,  you  have  before  you  the  whole  audible 
and  tangible  phenomena  of  the  heart's  action,  and  their  rela- 
tion to  the  physiological  movements  which  cause  them. 

Evidently  the  first  step  is  to  determine  which  is  the  first, 
and  which  is  the   second  sound  of  the  heart.    When  the 


*  In  treating  of  tlie  significance  of  the  cardiac  mumiur,  I  have  followed  Dr. 
Gairdner's  method  in  preference  to  any  other  with  which  I  am  acquainted,  and. 
in  some  instances  have  adopted  his  phraseology. 


98 


PHYSICAL  DIAGNOSIS. 


heart's  action  is  slow  and  regular,  this  is  quite  an  easy  matter ; 
but  when  the  heart  is  acting  rapidly,  it  is  always  difficult,  and 
sometimes  impossible,  to  distinguish  the  one  sound  from  the 
other.  It  is  important,  therefore,  not  only  to  know  theoreti- 
cally all  the  visible  phenomena  of  the  physiological  action  of 
the  heart,  but  it  should  be  a  famihar  tangible  knowledge. 
Having  identified  the  two  sounds,  and  traced  their  relation 

Fig.  15. 


Diagram  illustrating  the  3fode  rf  Production  of  Cardiac  Murmurs  in  the  Left  Heart,  and  the 
Condition  of  the  Valves  and  Cavities  during  their  Production.  By  substituting  the  words 
Tricuspid  and  Pulmonary,  for  Mitral  and  Aortic,  the  Diagram  will  similarly  illustrate  Mur- 
murs Occurring  in  the  Right  Heart. 


to  the  apex  beat,  and  the  radial  pulse,  the  rhythm  of  a  mur- 
mur is  readily  determined ;  for  all  valvular  murmurs  either 
precede,  or  take  the  place  of,  or  immediately  follow  one  of  the 
heart  sounds. 

First.  A  murmur  may  precede  and  run  up  to  the  first  sound, 
ending  at  the  moment  of  the  sound,  and  with  the  apex  beat. 
In  this  case,  as  shown  by  fig.  15,  the  murmur  is  simultaneous 
with  the  contraction  of  the  auricles,  and  is  called  a  mitral  or 
tricuspid  ohstructive  murmur,  as  it  is  produced  on  the  right  or 
left  side  of  the  heart,  while  the  blood  is  passing  from  the 


MUEMUES.  99 

auricles  to  the  yentricles.  Sucli  murmurs,  therefore,  depend 
either  upon  contraction  of  the  mitral  or  tricuspid  orifices,  or 
upon  deposits  on  the  auricular  surface  of  these  yalves, 
causing  obstruction  to  the  flow  of  blood  out  of  the  auricle 
during  its  contraction. 

Second.  A  murmur  may  take  the  place  of,  or  follow  the  first 
sound,  ending  somewhere  between  the  first  and  second  sounds. 
In  this  case  the  murmur  is  coincident  with  the  contraction 
and  emptying  of  the  ventricles,  and  must  be  caused,  as  is 
shown  in  fig.  15,  either  by  obstruction  to  the  current  of  blood 
as  it  flows  outwards  from  the  ventricles,  in  its  natural  direc- 
tion into  the  aorta  and  pulmonary  artery ;  or  backwards  by 
regurgitation,  through  the  mitral  or  tricuspid  valves.  If  it 
occur  on  the  left  side  of  the  heart,  it  is  called  either  aortic 
obstructive,  or  mitral  regurgitant  murmur ;  if  it  occur  on  the 
right  side  of  the  heart,  it  is  called  either  pulmonic  obstructive, 
or  tricuspid  regurgitant  murmur. 

Third.  A  murmur  may  take  the  place  of,  or  follow  the 
secoTid  sound,  ending  somewhere  during  the  interval  between 
the  second  and  first  sounds  ;  in  some  instances  it  may  be  pro- 
longed through  the  whole  period  of  rest.  This  murmur  is 
simultaneous  with  the  dilatation  of  the  ventricles  (fig.  15),  and 
is  produced  by  regurgitation  of  blood  through  the  aortic  or 
pulmonary  valves,  and  is  called  either  aortic  regurgitant  or 
pulmonic  regurgitant  murmur. 

We  may  have,  therefore,  eight  distinct  endocardial  murmurs, 
four  systolic,  and  four  diastolic.  Not  unfrequently  we  find  in 
practice,  various  combinations  of  these  different  murmurs  in 
the  same  case.  For  instance,  it  is  not  unusual  to  have  a 
mitral  obstructive  and  mitral  regurgitant  murmur  combined, 
so  as  to  appear  to  constitute  one  murmur  ;  the  first  sound  of 
the  heart  will,  however,  enable  you  to  separate  the  two  mur- 
murs. In  Hke  manner,  an  aortic  obstructive  and  regurgitant 
murmur  are  frequently  combined ;  here  also  the  sound  inter- 


100 


PHYSICAL  DIAGNOSIS. 


venes,  and  makes  the  rhytlim  quite  plain.  The  greatest  diffi- 
culty is  when  the  normal  sound  is  merged  into  the  murmur,  as 
is  often  the  case  when  the  mitral  obstructive  and  regurgitant 
are  combined. 

The  precise  pathological  significance  of  endocardial  murmurs 
is  apparent  from  the  following  table  : 

TABLE  OF  CARDIAC  MUEMTmS.* 


Periods  of 
Heart's  Action. 


Seat  of  Murmur. 


Systolic. 


Left     side 
of  heart. 


Aortic 


Mitral 


Cause  ofMwrmur. 

f  Obstruction  to  the  onward  flow  of  blood 
through  the  aortic  orifice,  or  througli 
the  aorta. 
Regurgitation  of  blood  through  the  mi- 
(^     tral  valve  into  the  left  auricle. 


Pulmonary 


Eight  side  _ 
of  heart 


Tricuspid 


'  Obstruction  to  the  onward  flow  of  blood 
through  pulmonary  orifice,  or  through 
pulmonary  artery. 

Regurgitation  of  blood  through  the  tri- 
cuspid orifice  into  right  auricle. 


Diastolic. 


C  Aortic 
Left     side  J 
of  heart,  i 

[Mitral 


Right  side 
of  heart. 


'Pulmonary 

Tricuspid   . 


Regurgitation    of  blood    through    the 
aortic  orifice  into  left  ventricle. 

Obstruction  to  the  flow  of  blood  from 
left  auricle  to  left  ventricle. 


Regurgitation  of  blood  through  the 
pulmonary  orifice  into  right  ven- 
tricle. 

Obstruction  to  flow  of  blood  from  right 
auricle  into  right  ventricle. 


Although  eight  distinct  valvular  murmurs  may  occur  in  the 
heart ;  those  on  the  right  side  are  of  such  rare  occurrence, 
that  they  are  of  little  clinical  importance.  If  a  murmur  is 
heard  with  the  first  sound  of  the  heart,  it  is  almost  certainly 
aortic  ohstrudive,  or  mitral  regurgitant;  if  with  the  second 
sound,  it  is  probably  aortic  regurgitant. 

An  obstructive  mitral  murmur  is  also  of  comparatively  rare 

♦After  Fuller. 


MITRAL  MURMURS.  JQl 

occurrence ;  the  force  with  which  the  blood  passes  from  the 
auricle  into  the  ventricle  being  ordinarily  insufficient  to  excite 
sonorous  vibrations. 

Seat  of  Murmurs. — Having  determined  the  rhythm  of  a 
murmur,  the  next  step  in  the  investigation  is  to  find  within  as 
narrow  limits  as  possible  the  place  of  its  origin.  The  points 
at  which  endocardial  murmurs  are  produced,  being  in  the 
majority  of  cases  one  of  the  four  valvular  orifices,  the  first 
question  to  be  settled  under  this  head  is,  at  which  one  of 
these  valvular  orifices  it  is  produced  ? 

At  the  commencement  of  the  examination,  every  means 
shoidd  be  taken  to  determine  in  each  particular  case  the 
actual  size  and  position  of  the  heart,  together  with  its  relation 
to  the  thoracic  walls  and  to  the  surrounding  organs,  the 
exact  point  of  the  apex  beat,  and  the  character  of  the  im- 
pulse. 

We  must  endeavor  by  careful  stethoscopic  examiuation 
to  determine  the  exact  seat,  and  the  limits  of  diffusion  of  the 
murmur  under  observation.  If  the  murmur  is  very  loud  or 
diffused,  or  if  there  are  several  murmurs  present  in  the  same 
case,  it  may  give  rise  to  some  difficulty ;  but  in  the  large 
majority  of  cases  the  observer  will  be  able  to  fix  on  a  few 
points,  or  a  few  restricted  spaces,  over  which  each  murmur 
is  heard,  there  being  no  murmur  elsewhere ;  or,  if  not  so, 
areas  within  which  each  murmur  is  heard  with  greatest 
intensity. 

As  there  are  four  valvular  orifices  at  which  the  majority  of 
endocardial  murmurs  are  produced,  so  there  are  four  distinct 
areas  to  which  murmurs  arisiug  at  these  orifices  may  be  prop- 
agated. 

The  following  rules  will  be  found  useful  in  recognizing  these 
areas  in  actual  practice  : 

I. — Area  of  Mitral  Murmurs. — The  maximum  of  intensity 
of  mitral  murmurs  corresponds  generally  with  the  apex  of  the 


102  PHYSICAL  DIAGNOSIS. 

left  ventricle,  represented  in  fig.  16  by  the  circle  A.  If  it  is 
produced  by  regurgitation  of  blood  through  mitral  orifice, 
its  area  of  diffusion  is  to  the  left,  on  a  line  corresponding  to 
the  apex  beat ;  the  seat  of  diffusion  in  front  corresponds  very 
nearly  to  the  circle  A,  fig.  16  ;  and  it  is  also  heard  with  very 

Fig.  16. 


Diagram  showing  the  Areas  of  Cardiac  Murmurs.  These  several  Areas  correspond  to  tht 
Different  Spaces  marked  by  the  Dotted  Lines,  and  a  Capital  Letter  Designates  each  Area. 
A,  the  Area  0/ Mitral  Murmurs ;  B,  of  Aortic;  C,  of  Tricuspid  ;  and  D,  of  Pulmonic— . 
Gajbdnbb. 

nearly  the  same  intensity  behind,  between  the  lower  border  of 
the  fifth,  and  upper  border  of  the  eighth  vertebra,  at  the  left 
of  the  spines  as  in  front. 
The   area  of  diffusion  of  mitral  obstructive  murmurs  is 


TRICUSPID  MURMURS.  2Q3 

usually  limited  to  a  circumscribed  space  (circle  A)  around  the 
apex  of  the  heart;  in  some  instances  these  murnftirs  are 
heard  with  equal  intensity  over  the  whole  superficial  cardiac 
region.  To  the  left  of  the  apex  beat  they  are  always  indis- 
tinct, and  are  never  heard  heliind. 

11.— Area  of  Tricuspid  Murmurs.— The  area  of  tricuspid 
murmurs  corresponds  to  that  portion  of  the  right  ventricle 
which  is  uncovered  by  lung  tissue,  indicated  in  the  diagram 
by  the  triangular  space  C.  This  murmur  is  distinct  and 
superficial  in  character,  rarely  audible  above  the  third  rib,  and 
thus  readily  distinguished  from  the  aortic  and  pulmonic  mur- 
murs. It  is  heard  loudest  near  the  xiphoid  cartilage,  and 
along  the  margins  of  the  sixth  and  seventh  costal  cartilages. 
In  cases  of  hypertrophy  and  dilatation  of  the  right  side  of 
the  heart,  usually  its  point  of  maximum  intensity  is  at  the 
junction  of  the  fourth  rib  with  the  sternum. 

Area  of  Pulmonic  Murmurs. — Murmurs  in  the  pulmonary 
artery,  or  at  the  pulmonary  valves,  are  carried  to  the  ear 
nearly  over  the  seat  of  the  valves,  as  indicated  by  the  circle 
D  in  the  diagram,  fig.  16.  Not  unfrequently  its  maximum 
point  of  intensity  is  an  inch,  or  even  an  inch  and  a  half,  lower 
down.  It  is  usually  very  superficial,  and  consequently  very 
distinct.  It  is  limited  in  its  diffusion,  being  inaudible  at  the 
apex,  and  also  along  the  sternum  ;  it  is  never  heard  in  the 
neck,  nor  in  the  course  of  the  great  vessels. 

Area  of  Aortic  Murmurs. — Tlie  law  of  diffusion  of  aortic 
murmurs  is  not  easily  explained ;  not  only  are  they  heard 
with  great  intensity  over  the  base  of  the  heart,  at  the  junction 
of  the  third  rib  with  the  sternum  on  the  left  side,  but  fre- 
quently, and  not  less  distinctly,  along  the  whole  length  of  the 
sternum,  as  is  indicated  by  the  dotted  lines  along  the  edge  of 
the  sternum,  in  the  in-egular  space  B,  fig.  16.  Sometimes 
they  are  absolutely  louder  close  to  the  xiphoid  cartilage  than 
at  any  other  point.    An  aortic  murmur  is  distinguished  from 


104  PHYSICAL  DIAGNOSIS. 

all  other  murmurs  by  being  propagated  into  the  arteries  of 
the  neck.  It  is  the  most  widely  diffused  of  all  cardiac  mur- 
murs, and  can  sometimes  be  traced  to  a  very  great  distance 
from  the  heart,  and  may  be  heard  behind  near  the  lower  angle 
of  the  scapula. 

To  complete  the  diagnosis  of  endocardial  murmurs  it  is 
necessary  to  consider  their  rhythm  in  connection  with  their 
area. 

First.  A  murmur  which  immediately  precedes  the  first  sound 
of  the  heart,  may  be  either  a  mitral  or  tricuspid  obstructive 
murmur,  and  is  produced  by  obstruction  to  the  current  of 
blood  as  it  passes  from  the  auricles  into  the  ventricles.  If  it 
is  a  mitral  obstructive  murmur,  its  maximum  of  intensity  will 
correspond  to  the  circle  A,  fig.  16 ;  if,  on  the  contrary,  it  is  a 
tricuspid  obstructive  murmur,  its  maximum  of  intensity  wiU 
be  within  the  triangle  C. 

Second.  Murmurs  accompanying  or  following  the  first  sound, 
and  occurring  between  the  first  and  second  sound,  may  be  pro- 
duced, either  in  the  auriculo-ventricular,  or  in  the  arterial 
orifices,  and  they  have  four  distinct  solutions. 

a.  If  a  murmur  following  the  first  sound  has  its  origin  at 
the  mitral  orifice,  it  is  a  mitral  regurgitant  murmur,  and  is  pro- 
duced by  regurgitation  of  the  blood  backwards  from  the  left 
ventricle  into  the  left  auricle.  Its  maximum  of  intensity  in 
front  will  correspond  to  the  circle  A,  fig.  16 ;  and  it  will  be 
heard  behind. 

h.  If  its  origin  is  at  the  tricuspid  orifice,  it  is  a  tricuspid  re- 
gurgitant murmur,  and  is  produced  by  regurgitation  of  the 
blood  backwards  from  the  right  ventricle  into  the  right 
auricle.  Its  maximum  of  intensity  will  correspond  to  the  tri- 
angle C,fig.  16. 

c.  If  its  origin  is  at  the  aortic  orifice,  it  is  an  aortic  obstruc- 
tive murmur,  and  is  produced  by  obstruction  to  the  current  of 
blood  as  it  passes  in  its  natural  course^  from  the  left  ventricle 


ANEMIC  AND  FUNCTIONAL  MURMURS.  105 

into  the  aorta.  Its  maximum  of  intensity  will  correspond  to 
the  irregular  space  B,  fig.  16. 

d.  If  its  origin  is  at  the  pulmonic  orifice,  it  is  a  pulmonic 
obstructive  murmur,  and  is  j)roduced  by  obstruction  to  the  cur- 
rent of  blood  as  it  passes  from  the  right  ventricle  into  the 
pulmonary  artery.  Its  maximum  of  intensity  will  correspond 
to  the  circle  D,  fig.  16. 

Again,  murmurs  accompanying  or  following  the  second  sound 
of  the  heart  may  be  produced  at  the  aortic  or  pulmonic 
orifice,  and  in  either  case  coincide  with  the  filling  of  the  ven- 
tricles. 

a.  If  a  murmur  accompanying  or  following  the  second 
sound  has  its  origin  at  the  aortic  orifice,  it  is  an  aortic  regurgi- 
tant murmur,  and  is  produced  by  the  regurgitation  of  the 
blood  from  the  aorta  backwards  into  the  left  ventricle.  Its 
maximum  of  intensity  corresponds  to  the  space  B,  fig.  16. 

h.  If  a  murmur  following  the  second  sound  has  its  origin  at 
the  pulmonic  orifice,  it  is  a  pulmonic  regurgitant  murmur,  and 
is  produced  by  the  regurgitation  of  blood  fi'om  the  pidmonary 
artery  into  the  right  ventricle.  Its  maximum  of  intensity 
corresponds  to  the  space  D,  fig.  16. 

One,  two,  three,  and  even  four  of  the  murmurs  we  have 
been  considering,  may  occur  in  combination  in  the  same  case. 
The  most  frequent  combinations  are  the  aortic  obstructive  and 
regurgitant  heard  over  the  area  B,  fig.  16 ;  next,  the  mitral 
obstructive  and  regurgitant  heard  over  the  area  A ;  then  we 
have  various  combinations  of  these,  the  aortic  and  mitral 
valves  being  both  diseased. 

Murmui's  occurring  on  the  right  side  of  the  heart  are  com- 
paratively of  rare  occurrence  ;  the  tricuspid  regurgitant  being 
the  only  one  that  is  of  practical  importance. 

Anaemic  and  Functional  Murmurs  are  soft  and  blowing  in 
character,  are  always  systolic,  and  almost  always  aortic.  As 
regards  their  area,  they  are  generally  diffused,  not  only  over 


106  PHYSICAL  DIAGNOSIS. 

the  base  of  the  heart,  but  along  the  course  of  the  aorta  and 
the  vessels  of  the  neck. 

An  anaemic  is  distinguished  from  an  organic  murmur  by  its 
blowing  character ;  by  always  accompanying  the  first  sound 
of  the  heart ;  by  being  audible  in  several  of  the  arteries  at 
the  same  time  ;  by  not  being  constantly  present,  occasionally 
disappearing  when  the  circulation  is  tranquil,  and  returning 
when  it  is  accelerated ;  by  the  presence  of  the  general  signs 
of  anaemia  ;  by  the  absence  of  the  physical  or  general  signs  of 
organic  disease  of  the  heart ;  by  entirely  disappearing  under 
treatment  calculated  to  relieve  the  anaemic  state  of  the 
system. 

Venous  Murmurs  all  come  under  the  class  of  inorganic 
murmurs.  The  so-called  venous  hum  is  a  continuous  hum- 
ming sound,  having  frequently  a  musical  intonation.  It  is 
best  heard  over  the  jugular  just  above  the  clavicles,  the 
patient  being  in  a  sitting  or  standing  position.  It  is  charac- 
teristic of  anaemia,  and  is  almost  always  associated  with  an 
arterial  anaemic  murmur. 

Before  leaving  the  subject  of  cardiac  murmurs,  I  wiU  give 
you  some  rules  in  relation  to  them,  copied  from  the  unpub- 
lished writings  of  the  late  Dr.  Cammann ;  they  are  the  result 
of  long  and  careful  observation,  and  although  they  differ  in 
some  respects  from  the  teachings  of  many  auscultators,  I 
have  found  them  of  great  service  in  diagnosis. 

Cardiac  Murmurs, 

Aortic  Obstructive  Systolic. 

"  "When  it  reaches  the  apex  it  is  with  diminished  intensity. 

"  When  heard  behind,  it  is  most  distinct  at  left  of  third 
and  fourth  vertebrae,  close  to  their  spines,  and  frequently  ex- 
tends downwards  along  the  spine  in  the  course  of  the  aorta, 
but  with  diminished  intensity.     Although  the  heart  only  ex- 


CARDIAC  MURMURS.  107 

tends  as  higb.  as  tlie  fiftli  vertebra,  tlie  murmur  is  heard 
above  that  point,  because  here  the  aorta  approaches  the  sur- 
face. 

Aortic  Regurgitant  Diastolic. 

"  The  intensity  of  the  murmur  from  valve  to  riglit  of  apex 
may  or  may  not  increase  downwards,  dependuig  on  the  prox- 
imity of  heart  to  parietes,  the  position  of  lungs,  etc. ;  it  may 
decrease  downwards,  however,  from  emphysema,  supine  re- 
cumbency, etc.,  or  may  perchance  be  loudest  at  apex;  de- 
pending on  proximity  of  heart  to  the  parietes,  position  of  the 
parts,  condition  of  the  mitral  valve,  etc. 

"  Generally  it  is  not  heard  behind,  but  may,  towards  inner 
side  of  lower  angle  of  scapula,  in  thin  subjects  especially,  be 
heard  in  the  same  place  where  is  heard  the  non-mitral  regurgi- 
tant ;  this  non-mitral  regurgitant  being  the  mitral  regurgi- 
tant of  BeDingham  and  others. 

"  It  is  sometimes  conveyed  to  left  axilla. 

"  The  patient  when  recumbent  may  sometimes  hear  it  him- 
self." 

3Iitral  Regurgitant  Systolic. 

"  To  indicate  regurgitation,  the  murmur  must  be  heard  be- 
tween lower  border  of  fifth,  and  upper  border  of  eighth  ver- 
tebra at  left  of  spine,  provided  the  transmission  of  the 
sound  be  not  interfered  with  by  thickness  of  integuments, 
or  other  conditions  of  the  parts. 

"  When  not  heard  in  this  place,  but  in  "  left  axilla  and  in  the 
region  of  the  left  scapula,"  regurgitation  is  not  indicated  ;  or, 
in  other  words,  it  is  a  non-regurgitant  murmur,  contrary  to 
the  teaching  of  Bellingham  and  others. 

"  If  there  be  a  systoHc  murmur  with  a  maximum  of  intensity 
between  fifth  and  eighth  vertebrae,  at  left  of  spine,  it  indicates 
regurgitation. 


108  PHYSICAL  DIAGNOSIS. 

"  An  aneurismal  murmur,  however,  may  be  heard  within  the 
said  Hmits,  but  it  follows  the  aorta  downwards,  gradually  de- 
creasing in  intensity,  without  the  abrupt  termination  of  the 
regurgitant  murmur. 

"We  occasionally  meet  with  mitral  regurgitant  murmur 
posteriorly,  yet  absent  anteriorly. 

"  The  mitral  regurgitant  murmur  may  sometimes  cease  en- 
tirely, from  such  a  change  in  the  structural  condition  of  the 
diseased  valve,  or  from  such  contraction  of  the  auriculo-ven- 
tricular  opening,  as  will  allow  the  valve  to  close  so  as  to  pre- 
vent regm'gitatiou,  there  being  actually  in  this  case  increased 
mechanical  obstruction. 

"  The  following  comj)hcation  may  exist ;  viz.,  aortic  ob- 
structive systolic,  with  aortic  regurgitant  diastohc  extending 
to  the  apex,  with  the  mitral  regurgitant  behind,  without  a  cor- 
responding murmur  in  front. 

"  All  these  murmurs  are  not  unfrequently  heard  to  right  of 
apex,  and  even  over  the  whole  chest. 

"A  mitral  diastohc  murmur  we  have  not  heard.  If  ever 
present,  as  stated  by  distinguished  auscultators,  it  must  de- 
pend upon  physical  condition  external  to  the  heart.  Thus, 
pleuritic  effusions,  or  the  hke,  in  certain  positions,  by  pressing 
suddenly  and  strongly  upon  the  left  auricle,  may  possibly 
force  the  blood  with  sufficient  rapidity  through  an  obstructed 
auriculo-ventricular  orifice  to  cause  an  abnormal  soimd. 

"  Some  auscultators,  however,  deny  the  possibihty  of  the 
occurrence  of  this  murmur  under  any  contingency  whatever." 


LESSON    XII. 

Synopsis  of  t?ie  'P/ij>sical  Signs  of  ^Pericarditis.  —ITyper- 
tropPiy,  dilatation,  and  JFatty  3)egenei'ation  of  Seart,  and 
ci.neu7^isms  of  Thoracic  A.orta. 

Synopsis  of  the  l^hysical  Signs  of  Pericarditis, 

The  physical  signs  of  pericarditis  vary  with  tlie  different 
stages  of  the  disease.  In  the  early  period  of  the  attack,  the 
only  sign  furnished  by  inspection  and  palpation  is  an  irritable 
and  forcible  action  of  the  heart,  and  there  is  no  change  in  the 
area  of  the  prsecordial  dnlness  on  percussion.  For  some 
time  the  only  characteristic  sign  of  its  presence  is  the  peri- 
cardial friction  sound.  After  a  time,  as  the  inflammation 
progresses,  effusions  take  place  into  the  pericardial  sac,  and 
we  have  the  second  stage,  or  stage  of  effusion. 

Inspection  now  discloses  a  prominence,  or  arching  forward, 
of  the  prascordial  region,  and  a  diminution  in  the  respiratory 
movements  of  the  left  side. 

Palpation  shows  the  point  of  the  apex  beat  to  be  raised 
and  carried  to  the  left  of  its  normal  position  ;  or,  if  the  quan- 
tity of  the  effusion  be  large,  it  is  entirely  suppressed.  Some- 
times, in  extensive  pericardial  effusions,  an  undulatory  im- 
pulse is  felt. 

Percussion. — The  area  of  the  prsecordial  dulness  is  en- 
larged vertically  and  laterally.  The  shape  of  the  enlarged 
area  corresponds  to  the  pyramidal  form  of  the  pericardial 
sac.  A  small  amount  of  effusion  is  denoted  by  an  increase  in 
the  width  of  the  area  of  dulness  at  the  lower  portion  of  the 


110  PHYSICAL  DIAGNOSIS. 

praBCordial  region.  "Wlien  tlie  sac  is  distended  with  fluid,  tlie 
dulness  will  reach  as  high  as  the  first  rib  ;  not  unfrequently  it 
reaches  an  inch  or  more  to  the  right  of  the  sternum,  and 
occasionallj  it  extends  from  nipple  to  nipple. 

Auscultation. — The  fi'iction  sound  of  the  early  stage 
ceases,  the  heart  sounds  become  feeble,  or  are  entirely  lost, 
and  the  respii'atory  murmur  and  vocal  resonance  are  absent 
over  the  area  of  praecordial  dulness. 

When  recovery  takes  place,  and  the  fluid  eflPusion  is  ab- 
sorbed, the  bulging  of  the  prsecordial  region,  which  was  pres- 
ent in  the  stage  of  effusion,  subsides,  and  the  area  of  dulness . 
on  percussion  decreases;  the  friction  sound  reappears;  the 
heart  sounds  become  distinct ;  the  apex  resumes  its  normal 
position ;  the  impulse  regains  its  natui'al  force,  and  the  respi- 
ratory and  vocal  sounds  are  again  heard  over  the  space  for- 
merly occupied  by  the  distended  pericardium. 

Synopsis  of  the  Physical  Signs  of  Hypertrophy  of  the 

Heart. 

The  physical  signs  of  hypertrophy  of  the  heart  vary  with 
the  seat  and  amount  of  the  hypertrophy.  When  the  hyper- 
trophy is  general,  inspection  shows  the  action  of  the  heart  to 
be  regular ;  the  extent  of  the  visible  impulse  to  be  increased ; 
the  apex  beat  lower,  and  more  to  the  left  than  natural ;  and 
in  children  there  is  a  visible  prominence  of  the  praecordial 
region. 

Palpation, — ^The  area  greatly  exceeds  that  within  which  the 
normal  apex  beat  is  felt,  and  the  impulse  has  a  heaving,  lift- 
ing character,  sometimes  felt  three  inches  below,  and  three  or 
four  to  the  left  of  its  normal  position. 

Percussion. — The  area  of  both  the  superficial  and  deep- 
seated  didness  increases  laterally  and  downwards.  If  the  hy- 
pertrophy is  confined  to  the  left  ventricle,  the  area  of  the  dul- 
ness on  percussion  may  extend  considerably  beyond  the  left 


HYPERTROPHY  OF  THE  HEART.  m 

nipple  ;  if,  on  the  other  liand,  the  hypei-trophy  is  confined  to 
the  right  ventricle,  the  area  of  dulness  may  extend  consider- 
ably to  the  right  of  the  sternum ;  if  the  hypertrophy  is  gen- 
eral, the  area  of  dulness  will  be  increased  both  to  the  right 
and  left. 

Auscultation. — The  first  sound  is  dull,  muffled,  and  pro- 
longed, and  in  some  cases  greatly  increased  in  intensity.  The 
second  sound  is  also  increased  in  intensity,  and  more  diffused 
than  in  health,  and  there  is  a  diminution  or  an  entire  absence 
of  the  respiratory  murmur  over  the  normal  praecordial  region. 

In  Hypertrophy  of  the  Heart  with  extensive  Dilata- 
tion, the  action  of  the  heart  is  still  regular,  but  the  extent  of 
the  visible  impulse  is  greatly  increased,  extending  sometimes 
from  the  third  intercostal  space  to  the  epigastrium.  The 
apex  beat  may  be  felt  as  low  as  the  ninth  rib,  and  to  the 
left  of  the  nipple,  and  is  of  a  pecuhar  heaving  character,  so 
as  sometimes  to  shake  the  bed  of  the  patient. 

The  area  of  dulness  may  extend  vertically  from  the  third  to 
the  eighth  rib  ;  and  laterally  two  inches  or  more  to  the  left  of 
the  left  nipple.  Both  sounds  of  the  heart  are  loud  and  pro- 
longed, and  are  often  audible  over  the  whole  chest,  even  to 
the  right  of  the  spine. 

Dilatation  of  the  Heart  -without  Hypertrophy  of  its 
Walls. — Inspection  and  palpation  disclose  indistinctness,  or  en- 
tire absence  of  the  cardiac  impulse,  and  an  irregular  and 
often  intermittent  action  of  the  heart. 

Percussion  shows  an  increase  in  the  area  of  praecordial 
dulness  do-wnwards  and  laterally. 

Auscultation  shows  the  first  sound  to  be  unnaturally  short, 
abrupt,  and  feeble ;  while  the  second  sound  is  often  inaudible 
at  its  apex ;  the  two  sounds  appear  to  be  of  equal  duration. 

Fatty  Dsgeneration  of  the  Heart. — The  physical  signs  of 
fatty  degeneration  of  the  heart  are  nearly  identical  with  those 
of  dilatation  without  hypertrophy  of  the  walls.     The  area  of 


112  PHYSICAL  DIAGNOSIS. 

prsecordial  dulness  is  normal ;  tlie  impulse  'weak  or  impercep- 
tible ;  the  apex  beat  indistinct,  and  often  invisible.  The 
action  of  the  heart  is  irregular ;  the  first  sound  is  short  and 
feeble,  and  sometimes  inaudible ;  the  second  sound  prolonged 
and  intensified. 

Aneuinsms  of  tJie  Tlioracic  Aorta. 

The  thoracic  aorta  is  affected  by  aneurism  with  varying  de- 
grees of  frequency  in  the  different  parts  of  its  course.  Ac- 
cording to  Sibson,  who  has  collected  the  statistics  of  703 
cases,  87  were  at  the  commencement  of  the  aorta  in  the  sinuses 
of  valsalva ;  193  at  the  ascending  arch,  extra  pericardial ;  14  at 
the  ascending  and  transverse  arch  ;  12  at  the  transverse  arch ; 
72  at  the  descending  arch ;  and  71  at  the  descending  aorta. 

The  physical  methods  employed  in  ascertaining  the  exist- 
ence of  aneurisms  are  impection,  palpation,  permssion,  and  ans- 
cultaiion. 

Inspection. — If  the  aneurism  presses  on  the  superior  vena 
cava,  you  will  observe  the  face,  neck,  and  upper  extremities 
to  be  swoUen,  hvid,  and  occasionally  oedematous ;  while  the 
veins  of  these  parts  are  turgid  and  varicose.  But  if  the  pres- 
sure is  only  on  the  innominata  veins,  these  effects  will  be  ob- 
served only  on  the  corresponding  side. 

In  some  instances,  there  is,  as  it  were,  a  thick  fleshy  collar 
surrounding  the  lower  part  of  the  neck,  due  to  cajoillary 
turgescence.  As  you  inspect  the  chest,  a  more  or  less  exten- 
sive bulging  may  be  observed  at  some  point  along  the  course 
of  the  aorta.  The  bulging  may  in  some  cases  attain  the  size 
of  a  cocoa-nut,  wliile  in  others  it  may  be  perceptible  only  on 
close  examination.  The  non-existence  of  a  tumor  does  not, 
however,  prove  that  there  is  no  aneurism,  for  if  the  aneuris- 
mal  enlargement  springs  from  the  posterior  wall  of  the  arch, 
or  from  the  descending  arch  or  descending  aorta,  parts  which 
are  deeply  seated,  there  may  be  no  visible  anterior  bulging. 


HYPERTROPHY  OF  THE  HEART.  1X3 

"When  the  bulgmg  portion  is  of  large  size,  it  is  generally 
conical  in  shape,  the  surface  being  smooth,  and  the  skin  looking 
tense  and  glazed.  In  most  cases  you  will  observe  a  pulsation 
of  the  tumor  synchronous  with  the  heart's  systole ;  where  this 
occurs  in  the  anterior  portion  of  the  chest,  there  seems  to  be  two 
beats  within  the  thorax  at  the  same  time.  Sometimes  you  can 
only  detect  the  pulsation  by  bringing  the  eye  to  a  level  with, 
and  looking  across  the  chest.  If  the  aneurism  is  full  of  fibrin 
there  may  be  no  visible  pulsation. 

The  position  of  the  bulging  affords  a  clue  to  the  seat  of  the 
aneurism.  Aneurisms  of  the  ascending  arch  produce  bulging 
to  the  right  of  the  sternum,  near  the  second  costal  cartilage  ; 
though  when  large  it  may  extend  into  both  mammary  and 
infra-clavicular  regions.  Aneurism  of  the  transverse  arch 
causes  protrusion  of  the  upper  part  of  the  sternum.  Aneu- 
rism of  the  descending  arch  protrudes  to  the  left  side  of  the 
sternum,  though  often,  from  the  deep  position  of  the  artery 
in  this  part  of  its  course,  no  tumor  may  exist.  Aneurism 
of  the  descending  aorta  shows  itself  on  the  left  side  of  the 
spine,  very  rarely  on  the  right. 

Palpation. — By  the  application  of  the  hand,  you  can  ap- 
preciate better  the  size  of  the  tumor,  the  nature  of  its  con- 
tents (whether  mostly  fluid  or  sohd),  the  condition  of  the  walls 
as  regards  perforation  of  the  sternum  or  ribs,  and  the  char- 
acter of  the  pulsation,  which  is  usually  that  of  a  blow  equally 
diffused  in  all  directions.  Besides  the  systoHc  impulse,  a 
diastolic  one  sometimes  occurs ;  generally  it  is  slight,  some- 
times, however,  it  is  quite  forcible.  In  some  cases  you  will 
obtain  the  impulse  by  pressing  with  one  hand  on  the  sternum, 
and  the  other  on  the  back,  when  by  ordinary  palpation  you 
would  not  detect  it.  Again,  a  thrill  may  be  communicated  to 
the  hand,  if  the  aneurism  is  at  the  upper  portion  of  the  arch ; 
by  pressing  the  fingers  down  behind  the  sternum  a  distinct  im- 
pulse will  be  felt.    You  may  also  ascertain  whether  there  is  a 


114  PHYSICAL  DIAGNOSIS. 

cessation  or  diminution  of  the  expansive  movement  over  tlie 
whole  or  part  of  one  lung,  and  whether  the  vocal  fremitus  is 
lost  over  that  side,  and  over  the  tumor. 

The  non-expansion  and  loss  of  vocal  fremitus  over  the  lung 
is  due  generaUj  to  the  pressure  of  the  aneurism  on  the  air 
passages,  or  on  the  lung  itseK.  When  the  aneurism  presses 
on  the  carotid  arteries,  or  when  they  are  obstructed  by 
coagula,  a  difference  between  the  pulse  of  these  arteries  and 
theu'  bronchi  on  the  two  sides  will  be  noticed. 

Percussion. — There  will  be  dulness  over  the  prominence,  or 
over  a  circumscribed  space,  in  the  neighborhood  of  the  course, 
of  the  aorta,  not,  however,  corresponding  to  the  size  of  the 
aneurism,  unless  more  forcible  percussion  be  made  than  is 
safe.  The  resistance  is  increased  in  proportion  to  the  amount 
of  the  fibrin  in  the  sac.  "^^Tien  the  lung  is  condensed  by  in- 
flammation, or  collapsed  by  obstruction  of  the  bronchus, 
there  will  be  a  greater  area  of  dulness. 

Auscultation. — Connected  with  an  aneurism  there  are 
usually  certain  sounds  or  murmurs.  In  some  cases  neither 
are  audible,  owing  either  to  the  position  of  the  aneurism,  to 
the  solidity  of  its  contents,  or  to  the  nature  of  its  orifice. 
These  sounds  resemble  those  of  the  heart,  and  are  similarly 
called  systohc  and  diastolic  ;  they  may  be  either  equal  to,  or 
weaker  or  louder  than,  those  of  the  heart :  the  systolic  may 
exist  alone,  either  or  both  sounds  may  be  replaced  by  a  mur- 
mur ;  for  instance,  there  may  be  a  systohc  murmur  only,  or 
you  may  have  both  a  systolic  and  a  diastohc  sound.  The 
character  of  the  murmur  varies.  It  is  usually  short,  abrupt, 
of  low  pitch,  and  as  loud  as  or  louder  than  the  loudest  heart 
murmur.  It  may  be  rasping,  sawing,  filing,  etc.  The  dias- 
tohc murmur  is  rarer  than  the  systohc,  and  is  usually  of  a 
softer  quahty.  "Where  the  aneurism  compresses  a  large 
bronchus,  the  respiratory  murmur  over  the  whole  or  a  part  of 
one  side  ■will  be  weak  or  suppressed ;  on  the  opposite  side  it 


HYPERTROPHY  OF  THE  HEART.  hk 

will  be  exaggerated.  There  is  also  loss  of  vocal  resonance 
over  the  aneurism,  and  over  the  lung  whose  bronchus  is  ob- 
structed. Where  the  lung  is  condensed  from  pressure,  the 
breathing  will  be  bronchial ;  where  there  is  pressure  over  the 
trachea  or  bronchi,  the  breathing  may  be  stridulous,  and  be 
rightly  referred  to  a  lower  point  of  production  than  the 
larynx.  Where  there  is  irritation  of  the  recurrent  laryngeal 
nerve,  this  type  of  breathing  may  come  from  spasm  of  the 
glottis. 

Differential  Diagnosis.— You  will  find  that  the  principal 
difficulties  in  diagnosis  are  between  aneurisms  and  intra-tho- 
racic  tumors. 

The  latter  are  rare  :  they  rarely  pulsate,  or,  if  they  should, 
they  will  communicate  to  the  hand  a  mere  hfting  pulsation ; 
in  some  instances  malignant  tumors  have,  however,  a  true 
expansive  impulse.  Again,  intra-thoracic  tumors  are  not 
usually  developed  entirely  in  the  tract  of  the  aorta ;  their 
area  of  dulness  is  large,  and  the  resistance  communicated  to  the 
finger  on  percussion  is  usually  great.  As  a  rule  there  are  no 
sounds  or  murmurs  connected  with  them,  though  in  some 
cases  where  a  tumor  is  placed  over  the  aorta,  a  murmur  may 
occur.  Tumors  are  more  apt  to  produce  persistent  swelling, 
and  oedema  of  the  upper  extremities,  neck,  and  face.  In  a 
case  of  aneurism,  this  latter  sign  may  become  developed,  and 
then  disappear,  owing  to  a  change  in  the  direction  of  the  pres- 
sure. Tubercular  consolidation  of  one  apex,  if  associated  with 
a  murmur  in  the  sub-clavian  or  pulmonary  artery,  might  be 
mistaken  for  an  aneurism.  In  the  former  we  have  the  physi- 
cal signs  of  phthisis.  The  murmur  is  heard  in  the  course  of 
the  pulmonary  or  sub-clavian  artery.  The  dulness  is  not  cir- 
cumscribed, and  extends  outwards,  and  not  across  the  median 
line. 

Pulsatile  Empyema,  it  seems  to  me,  could  hardly  be  mis- 
taken for  aneurism,  although  such  instances  are  on  record, 


116 


PHYSICAL  DIAGNOSIS 


for  it  does  not  occupy  the  position  of  an  aneurism.  Then 
you  have  the  physical  signs  of  effusion  into  the  plural  sac, 
and  it  is  attended  by  no  sounds  or  murmurs. 

Aneurism  of  the  Arteria  Innominata  is  distinguished  from 
aneurism  of  the  thoracic  aorta,  by  the  fact  that  the  tumor 
appears  early  on  the  right  of  the  sternum ;  as  it  increases,  it 
protrudes  the  inner  part  of  the  clavicle,  or  extends  upwards 
into  the  neck.  Its  pulsation  is  diminished  or  suspended  by 
pressure  on  the  carotid  or  sub-clavian  artery,  while  an  aneu- 
rism of  the  aorta  will  not  be  affected  by  such  pressure. 


ABDOMEN. 


LESSON    XIII. 

Introductio7i.—Topoff7'ap?ij>  of  the  Abdomen.— Contenis  of  the 
Yarious  ^effions.—A.bdominal  Inspection,  'Palpation,  Per- 
cussion, and  Auscultation.— l>iseased  Conditions  of  the 
^eritoneuin. 

Theke  are  difficulties  in  tlie  physical  exiDloration  of  tlie  abdo- 
men which  are  not  met  with  in  similar  examinations  of  the 
thorax.  * 

First.  Thoracic  diseases  involve  in  their  diagnosis  the  ex- 
amination of  only  one  or  two  organs,  or  their  appendages ; 
while  an  abdominal  affection  may  require  for  its  diagnosis  the 
examination  of  ten  or  twelve  organs.  Thus  a  tumor  in  the 
left  side  may  be  either  an  enlarged  mesenteric  gland,  or  it 
may  be  connected  with  the  stomach,  spleen,  kidneys,  ovaries, 
or  uterus ;  or  it  may  be  a  hernia,  an  abscess,  a  hydatid  cyst, 
an  aneurism,  or,  lastly,  only  a  lump  of  faeces. 

Second.  The  action  of  the  thoracic  organs  is  regular  and 
rhythmical,  and  their  contents  unvarying ;  while  the  action 
of  the  abdominal  viscera  is  often  in-egTdar  and  intermittent. 
An  abdominal  organ  may  also  at  one  time  be  greatly  distended 
with  contents,  and  soon  after  be  empty ;  when  filled,  its  con- 
tents may  be  soHd,  fluid,  or  gaseous,  or  all  these  together. 
The  lungs  and  heart  contain  respectively  the  same  quantities 
of  air  and  blood  during  every  five  minutes  of  ordinary  life,  but 
the  stomach  and  bladder  can  never  remain  long  in  one  condi- 
tion, either  full  or  empty. 

Third.  The  abdominal  organs  are  packed  loosely  in  a  cavity 
with  loose  walls.     They  therefore  can  be  increased  or  de- 


120  PHYSICAL  DIAGNOSIS. 

creased  in  size,  so  as  to  alter  wholly  their  relations  to  their 
fellow  organs.  Thus  the  uterus,  usually  the  smallest,  will,  in 
fulfilling  its  natural  function,  become  much  the  largest  of  all, 
tiU  it  crowds  even  the  thoracic  organs  ;  moreover,  in  disease, 
a  single  ovary  may  sweU  into  a  sac  which  ■uill  fill  entirely  the 
abdominal  cavity.  These  constitute  the  chief  difficulties  in 
the  physical  examination  of  the  abdomen,  and  they  must 
always  throw  a  certain  degree  of  doubt  upon  all  physical 
diagnosis  directed,  to  this  part  of  the  body. 

To  facilitate  our  examinations,  and  to  render  our  inferences 
more  certain,  it  is  weU  to  divide  the  abdomen  into  regions  by 
passing  imaginary  planes  through  the  body. 

The  divisions  which  have  been  proposed  by  different  observ- 
ers vary  somewhat.  The  following,  proposed  by  Dr.  Bright, 
wiU,  I  think,  be  found  most  useful : 

The  abdomen  may  be  divided  into  three  general  zones, — 
the  epigastric,  the  umbilical,  and  the  hypogastric. 

The  Epigastric  zone  is  bounded  above  by  the  diaphragm, 
below  by  a  horizontal  plane  passing  through  the  anterior  ex- 
tremities of  the  tenth  rib  on  either  side.  In  a  well-formed 
chest  the  cartilage  of  the  tenth  rib  on  either  side  offers  a  pro- 
jection at  its  lower  convex  border,  which  can  be  felt  without 
difficulty ;  a  horizontal  plane  carried  backwards  through  these 
points  will  pass  between  the  bodies  of  the  first  and  second 
lumbar  vertebra.  This  zone  is  subdivided  into  the  epigas- 
tric, and  the  right  and  left  hypochondriac  regions,  which  cor- 
respond to  the  spaces  bounded  by  the  false  ribs. 

The  Umbilical  zone  is  bounded  above  by  the  lower 
boundary  of  the  epigastric,  and  below  by  a  horizontal  plane 
passing  through  the  anterior  and  superior  spinous  processes 
of  the  iha  ;  this  plane,  if  carried  backwards,  will  pass  between 
the  second  and  third  sacral  spines. 

The  Hypogastric  zone  is  bounded  above  by  the  lower 
boundary  of  the  umbilical  zone ;  below,  in  the  centre,  by  the 


TOPOGRAPHY  OF  THE  ABDOMEN. 


121 


upper  margin  of  the  pubes  ;  on  either  side  by  Ponpart's  liga- 
ment. This  zone  occupies  the  whole  cavity  of  the  true 
pelvis.  The  umbilical  and  hypogastric  zones  have  each  three 
subdivisions  made  by  two  vertical  planes,  passing  backwards 
through  the  spinous  processes  of  the  pubes  and  the  points  on 
the  tenth  ribs  abeady  alluded  to.  The  subdivisions  of  the 
umbilical  zone  thus  produced  are  termed  the  central  or  um- 
bilical,  and  two  lateral,  or  the  rigJit  and  left  lumbar.    The  sub- 


Fig.  17. 


Diagram  shoviing  the  different  Regions  of  the  Ahdomm,  and  the  Organs  contained  in  each,  wMch 
are  visible  on  the  removal  of  the  Abdominal  Walls. 

divisions  of  the  hypogastric  thus  produced  consist  of  the 
middle  or  j^^ibic,  and  the  lateral  or  right  and  left  iliac. 

The  organs  contamed  m  these  regions  in  health  are  as 
follows  : 

The  Epigastric  region  contains  the  whole  of  the  left,  and  a 


122  PHYSICAL  DIAGNOSIS. 

part  of  the  right  lobe  of  the  liver ;  the  gall  bladder  ;  the 
pyloric  orifice  of  the  stomach ;  the  commencement  of  the 
duodenum ;  a  portion  of  the  colon ;  the  pancreas ;  the  aorta, 
and  the  csehac  axis  :  and  I  would  earnestly  recommend  to 
you,  gentlemen,  to  study  both  here  and  in  the  other  regions 
the  position  of  the  parts  relatively  to  one  another. 

The  Right  Hypochondriac  region  contains  nearly  the  whole 
of  the  right  lobe  of  the  liver  ;  the  angle  of  the  ascending  and 
a  portion  of  the  transverse  colon ;  the  greater  part  of  the  duo- 
denum ;  the  renal  capsule,  and  the  upper  portion  of  the  right 
kidney. 

The  Left  Hypochondriac  region  contains  the  rounded  car- 
diac portion  of  the  stomach,  at  all  times,  and  a  very  large  por- 
tion of  the  organ  when  distended  ;  the  left  angle  of  the  colon ; 
the  spleen,  and  a  small  portion  of  the  left  kidney,  with  its 
renal  capsule. 

The  Umbilical  region  is  chiefly  occupied  by  a  portion  of 
the  arch  of  the  colon,  the  omentum,  and  the  small  intestines. 
It  contains,  likewise,  the  mesentery  and  its  glands,  the  aorta, 
and  the  vena  cava. 

The  Right  Lumbar  region  contains  the  caecum,  the  ascend- 
ing colon,  the  lower  and  middle  portion  of  the  kidney,  and  a 
portion  of  the  ureter. 

The  Left  Lumbar  region  is  occupied  by  the  descending 
colon,  the  left  kidney,  and  the  ureter.  The  small  intestines 
likewise  occupy  the  lumbar  region  on  either  side. 

The  Pubic  or  Hypogastric  region  contains  in  children, 
the  urinary  bladder,  with  portions  of  the  ureters  (also  in 
adults  if  they  be  distended),  the  convolutions  of  the  small  in- 
testines, and  in  the  female,  the  uterus  and  its  appendages. 

The  Right  Iliac  region  contains  the  "  cul-de-sac  "  of  the 
caput  cob  ;  the  vermiform  process,  and  the  iliac  vessels. 

The  Left  Iliac  region  contains  the  sigmoid  flexure  of  the 
colon,  and  the  iliac  vessels  of  that  side. 


EXAMINATION  OP  THE  ABDOMEN.  123 

Methods  Employed  in  the  Physical  Examinations  of  the 

Abdomen. 

They  are  the  same,  with  the  exception  of  succussion,  as 
those  practised  in  exploration  of  the  thorax.  But  they  differ 
in  their  relative  importance.  In  thoracic  examinations,  aus- 
cultation is  the  most  important  method ;  while  in  abdominal 
examinations,  auscultation  is  only  employed  in  determining 
the  existence  of  aneurisms  and  of  pregnancy.  Percussion 
and  palpation  are  the  means  by  which  we  gain  the  most  use- 
ful information  concerning  the  contents  of  the  abdominal 
cavity. 

Before  considering  the  signs  which  indicate  the  changes 
occurring  in  the  different  affections  of  the  abdominal  organs, 
I  will  briefly  notice  the  different  methods  of  exploration. 

Inspection. — By  it  we  note  alterations  in  the  shape  and 
movements  of  the  abdomen.  It  is  most  satisfactorily  per- 
formed with  the  patient  lying  on  the  back,  with  the  thighs 
shghtly  flexed.  In  health,  the  abdomen  is  of  an  oval  form, 
marked  by  elevations  and  depressions  corresponding  to  the 
abdominal  muscles,  the  umbilicus,  and  in  some  degree  by  the 
form  of  the  subjacent  viscera ;  it  is  larger  relatively  to  the 
size  of  the  chest,  in  children,  than  in  adults,  more  rotund,  and 
broader  inferiorly,  in  females  than  in  males. 

Alterations  in  its  shape  due  to  disease,  we  find  to  consist, 
First,  in  enlargement .,  which  may  be  general  and  symmetrical,  as 
in  ascites  ;  or  partial  and  irregular,  from  tumors,  hypertrophy 
of  organs,  as  the  Kver  and  spleen  ;  or  from  tympanitic  disten- 
sion of  portions  of  the  intestines  by  gas,  as  of  the  colon  in 
typhoid  fever.  Second,  it  may  be  retracted  as  in  extreme 
emaciation,  and  in  several  forms  of  cerebral  disease ;  es- 
pecially is  this  noticeable  in  the  tubercular  meningitis  of 
children. 

The  normal  movements  of  the  abdominal  walls  are  con- 


124  PHYSICAL  DIAGNOSIS. 

nected  with  the  respiration,  so  that  thej  bear  a  certain  rela- 
tion to  the  movements  of  the  chest  walls,  being  often  in- 
creased when  the  latter  are  arrested,  and  vice  versa.  Thus 
abdominal  movements  are  increased  in  pleurisy,  pneumonia, 
pericarditis,  etc. ;  but  decreased  or  wholly  suspended  when 
disease  causes  abdominal  pain,  or  in  peritonitis. 

Not  imfrequently,  when  inspecting  the  abdomen,  a  distinct 
pulsation  will  be  visible  in  the  epigastric  region,  which  fre- 
quently is  mistaken  for  aneurism.  The  superficial  abdominal 
veins  are  also  at  times  visibly  enlarged,  radicating  an  obstruc- 
tion to  the  current  of  blood  either  in  the  portal  system,  as  in 
cirrhosis,  or  in  the  vena  cava. 

Mensuration  is  mainly  useful  in  determining  the  exact  in- 
crease or  decrease  of  abdominal  dropsies,  visceral  enlarge- 
ments, and  tumors.  It  is  performed  by  means  of  a  graduated 
tape. 

Palpation. — This  method  of  exploration  often  furnishes 
important  information.  It  may  be  performed  with  the  tips  of 
the  fingers,  with  the  whole  hand,  or  with  both  hands,  and  the 
pressure  may  be  shght  or  forcible,  continuous  or  alternate. 
In  order  to  obtain  the  greatest  amount  of  information  by  pal- 
pation, the  patient  should  be  placed  in  a  horizontal  position, 
with  the  head  sHghtly  raised  and  the  thighs  flexed ;  some- 
times it  is  necessary  to  place  him  in  a  standing  position,  or 
leaning  forward. 

Indications  Furnished  by  Palpation. — By  it  we  can  de- 
termine the  size  and  position  of  the  viscera,  the  existence  of 
tumors  and  swellings,  whether  they  are  superficial  or  deep, 
large  or  small,  hard  or  soft,  smooth  or  nodulated,  movable  or 
fixed,  solid  or  fluid,  and  whether  or  not  they  possess  a  motion 
of  their  own.  We  can  also  ascertain  if  tenderness  exist  in 
any  portion  of  the  abdominal  cavity,  and  if  pain  is  increased 
or  relieved  by  firm  pressure. 

Percussion. — In  the  performance  of  abdominal  percussion, 


EXAMINATION  OP  THE  ABDOMEN.  125 

the  patient  should  be  placed  in  the  same  position  as  for  pal- 
pation, and  the  percussion  should  be  for  the  most  part 
mediate.  In  exploring  the  abdomen  by  means  of  percussion, 
the  plessimeter  (the  finger  being  the  best)  should  first  be 
placed  immediately  below  the  xiphoid  cartilage,  pressed  firmly 
down  and  carried  along  the  median  line  towards  the  pubes, 
striking  it  all  the  way,  now  forcibly,  now  gently.  The  differ- 
ent tones  which  the  stomach,  colon,  and  small  intestines  fur- 
nish will  be  distinctly  heard.  The  percussion  should  then  be 
made  laterally,  alternately  to  the  one  side  and  then  to  the 
other,  until  the  whole  surface  is  percussed  (Bennet).  In  this 
manner  the  different  percussion  sounds  of  the  stomach,  large 
intestines,  small  intestines,  and  the  sohd  viscerae  will  be  readily 
distinguished.  Thus  the  percussion  sound  elicited  over  a 
healthy  abdomen  may  be  dull,  fiat,  or  tymjpanitic.  Over  the 
centi'al  portion  of  the  liver,  spleen,  and  kidneys,  the  percus- 
sion sound  is  flat ;  over  that  portion  of  either  of  these  organs 
where  they  overlap  the  intestines  or  stomach  it  is  dull,  with  a 
tympanitic  quality.  Over  the  stomach  and  intestines  it  is  tym- 
panitic, more  so  over  the  former  than  the  latter.  When  fluid 
occupies  the  abdominal  cavity,  over  the  fluid  the  percussion 
sound  will  be  flat.  A  distended  bladder  or  uterus ;  an  enlarged 
liver,  spleen,  kidney,  or  mesenteric  gland  ;  ovarian,  aneurismal, 
and  other  tumors,  are  recognized  and  their  limits  determined 
by  the  unnatural  and  increased  area  of  the  percussion  flatness  ; 
while,  on  the  other  hand,  gaseous  distension  of  the  stomach 
or  intestines  is  recognized  by  the  increased  area  of  tympan- 
itic percussion. 

Auscultation. — For  the  physical  exploration  of  the  abdo- 
men, auscultation  is  only  of  service,  as  we  have  said  before,  in 
the  diagnosis  of  aneurisms,  and  in  detecting  the  pulsations  of 
the  foetal  heart,  and  the  utero-placental  murmur  in  the  preg- 
nant state. 

Our  examinations  of  the  abdominal  viscera  are  sometimes  in- 


126  PHYSICAL  DIAGNOSIS. 

terfered  with  and  rendered  uncertain  by  clianges  tliat  occur 
in  the  abdominal  walls.  Generally,  the  abdominal  walls  are 
sufficiently  thin,  soft,  and  movable  for  us  to  determine  with 
considerable  accuracy  the  situation  and  condition  of  the  con- 
tained organs  :  if,  however,  everything  is  masked  by  layer 
upon  layer  of  fat,  as  in  some  cases  of  obesity,  abdominal  ex- 
aminations will  be  unsatisfactory.  An  (Edematous  condition  of 
the  abdominal  walls,  as  in  Bright's  disease,  may  also  prevent 
us  from  ascertaining  the  condition  of  the  viscera.  When  this 
occurs,  the  surface  of  the  abdomen  presents  a  smooth,  even, 
shining,  waxy  appearance,  and  pits  on  firm  pressure.  Su- 
perficial abscess  of  the  abdominal  walls  also  occurs  occasionally, 
which  interferes  greatly  with  the  exploration  of  the  abdominal 
cavity.  You  can  recognize  these  by  the  circumscribed  bulg- 
ing, by  tenderness  on  shght  pressure,  by  the  redness  of  the 
surface,  and  by  the  characteristic  fluctuation  of  a  superficial 
abscess. 

The  abdominal  muscles  are  sometimes  abnormally  devel- 
oped, or  unnaturally  rigid  as  in  tetanus,  rheumatic  inflamma- 
tion, and  in  the  early  stage  of  peritonitis,  and  this  somewhat 
interferes  with  our  examinations. 

jyiseased  Conditions  of  the  Peritoneum. 

Under  this  head  may  be  included  the  various  resiilts  of  in- 
flammatory action,  ascites,  etc.  They  all  give  rise  to  more  or 
less  abdominal  enlargement. 

Acute  Peritonitis. — By  inspection  we  recognize  in  acute 
peritonitis  either  a  diminution  or  an  entire  suspension  of  ab- 
dominal respiration,  the  breathing  becoming  entirely  thoracic. 
The  abdomen  enlarges,  becomes  unnaturally  tympanitic,  and 
there  is  marked  tenderness  on  flrm  pressure.  The  compara- 
tive results  of  firm  and  slight  pressure  is  one  of  the  sti'ong 
diagnostic  marks  of  peritoneal  inflammation. 

Chronic  Peritonitis  is  ahnost  always  connected  with  tuber- 


PERITONEUM. 


127 


cular  and  cancerous  deposits  in  the  substance  and  over  the 
free  surface  of  the  peritoneum ;  and  in  addition  to  the  tym- 
panitic distension  of  the  abdomen,  and  the  tenderness  on  firm 
pressure  noticed  in  acute  peritonitis,  fluid  accumulations  take 
place  in  the  peritoneal  cavity. 

Ascites. — A  collection  of  fluid  from  any  cause  in  the  peri- 
toneal cavity  is  termed  ascites. 

Inspection. — The  abdomen  is  always  uniformly  enlarged, 
and  the  movements  of  the  abdomen  in  respiration  are  either 
suspended  or  limited  to  the  epigastric  region.  The  superficial 
abdominal  veins,  if  the  ascites  depend  upon  disease  of  the 
liver,  will  often  be  found  enlarged. 

Palpation. — If  the  palmar  surface  of  the  hand  be  applied  to 
the  side  of  the  abdomen  at  the  level  of  the  fluid,  and  hght 
percussion  be  performed  on  the  opposite  side,  a  sense  of  fluc- 
tuation will  be  communicated  to  the  hand. 

Percussion  gives  flatness  at  the  lower  and  most  depending 
portion  of  the  abdomen ;  while  at  the  upper  portion  above  the 
level  of  the  fluid,  there  is  a  drum-like,  tympanitic  resonance. 
When  the  patient  is  in  the  erect  posture,  the  tympanitic  reso- 
nance is  confined  to  the  epigastrium  and  upper  portion  of  the 
umbihcal  region.  If  in  a  recumbent  posture,  the  tympanitic 
resonance  will  extend  into  the  hypogastrium  ;  if  placed  on 
either  side,  the  lumbar  region  of  the  opposite  side  becomes 
tympanitic.  Other  abnormal  changes  that  occur  in  the  peri- 
toneum are  connected  with  deposits,  that  may  be  classed 
under  the  head  of  abdominal  tumors. 


LESSON    XIV. 

Physical  Siffns  of  the  c±bnormat   Chajiges  in   the  different 
A.bdominal  Orffcins. — Stomach. — Intestines. — Hrer. — Spleen. 

Stomach. — When  this  viscus  is  empty,  or  not  distended 
with  gas  or  food,  there  is  on  insjiection  no  visible  prominence 
to  indicate  its  position,  nor  does  j^cdpcition  furnish  us  any  in- 
formation as  to  its  condition. 

Percussion  gives  a  metallic  or  tympanitic  resonance  which 
enables  us  to  distinguish  it  from  the  surrounding  viscera. 
The  line  of  dulness  which  marks  the  lower  border  of  the  liver 
and  the  inner  border  of  the  spleen  determines  the  upper  and 
lateral  boundaries  of  the  stomach.  To  ascertain  the  lower 
border,  percuss  gently  downwards  from  this  line  of  dulness, 
until  a  slight  change  in  the  percussion  sound  indicates  that 
you  have  reached  the  transverse  colon  (see  fig.  17).  Opposite 
the  inner  border  of  the  seventh  rib  the  cardiac  orifice  or  ex- 
tremity of  the  organ  is  situated.  At  a  poiat  a  little  below  the 
lower  border  of  the  liver,  within  a  line  drawn  from  the  right 
nipple  to  the  umbilicus,  the  pyloric  orifice  of  the  organ  is  situ- 
ated. The  lower  margin  of  the  great  "  cul-de-sac  "  is  found 
generally  near  the  umbilicus. 

Diminution  in  the  size  of  the  stomach  cannot  be  recognized 
by  physical  exploration.  An  increase  in  size  or  distension  of 
the  stomach  may  occur  from  an  accumulation  of  gas,  from 
large  quantities  of  fluids  or  solids  taken  into  the  stomach ;  or 
it  may  be  enlarged  within  circumscribed  spaces  from  cancer- 
ous deposit  ia  its  walls. 


INTESTINES. 


129 


Gaseous  or  Tympanitic  distension  of  tlie  stomacli  is  rec- 
ognized by  an  increase  in  the  area  of  the  characteristic  tym- 
panitic resonance  of  the  organ.  A  distended  condition  of  the 
stomach  from  food  or  drink  is  recognized  by  an  absence  of 
the  normal  resonance,  and  by  a  continuation  of  the  dull  per- 
cussion of  the  liver  and  spleen  downwards  to  the  umbihcus. 
A  moderate  amount  of  fluid  or  soHd  in  the  stomach  can  be 
determined  by  a  limited  area  of  duhiess  corresponding  to  the 
"  cul-de-sac  "  of  the  organ. 

Cancer  of  the  Stomach  most  frequently  has  its  seat  at  the 
pyloric  extremity  of  the  organ ;  but  in  whatever  portion  of  the 
organ  it  may  be  developed,  it  can  be  recognized  by  circum- 
scribed dulness  on  percussion,  where  in  health,  when  the 
stomach  is  empty,  we  should  have  tympanitic  resonance. 
The  percussion  dulness  elicited  over  the  cancerous  mass,  how- 
ever, has  a  hollow  character  which  is  readily  distinguished 
from  the  flat  percussion  sound  of  a  sohd  organ. 

By  palpation  a  nodulated  mass  is  readily  detected,  corre- 
sponding to  the  area  of  percussion  duhiess,  which  is  movable, 
easily  grasped,  and  readily  separated  from  the  surrounding 
viscera.  These  signs,  taken  in  connection  with  the  attendant 
symptoms,  are  almost  always  sufficient  for  a  positive  diagnosis. 

Intestines. — In  a  normal  condition  the  large  intestine  fur- 
nishes a  more  amphoric  percussion  sound  than  the  stomach. 
When,  however,  they  are  filled  with  fluid  or  sohd  accumula- 
tions, the  situation  of  these  accumulations  can  be  marked  out 
on  the  surface  by  the  duhiess  on  percussion. 

The  peculiar  feeling  of  such  enlargements  will  generally 
enable  you  to  decide  as  to  their  true  character  ;  they  feel  like 
no  other  tumors.  On  being  examined  through  the  abdominal 
walls,  they  are  felt  to  be  hard  and  resistant ;  but  if  one  finger 
be  pressed  steadily  upon  them  for  one  or  two  minutes,  they 
-will  at  last  indent  like  a  hard  snowball ;  and  as  there  is  not 
the  slightest  elasticity  about  them,  the  indentation  remains 


130  PHYSICAL  DIAGNOSIS. 

after  tlie  pressure  is  removed  (Simpson).  As  tliese  accumula- 
tions most  frequently  collect  in  tlie  descending  colon,  the  per- 
cussion sound  over  this  portion  is  usually  less  resonant  than 
over  the  ascending  or  transverse  colon.  According  to  Dr. 
Bennet,  in  a  practical  point  of  view  it  is  often  useful  to  deter- 
mine whether  a  purgative  by  the  mouth  or  an  enema  is  Hkely 
to  open  the  bowels  most  rapidly.  If  there  is  dulness  ia  the 
left  ihac  fossa  in  the  track  of  the  descending  colon,  that  por- 
tion of  the  intestine  must  be  full  of  fseces,  and  an  enema  is 
indicated.  If,  on  the  other  hand,  the  sound  in  the  left  iliac 
fossa  is  tympanitic,  and  in  the  right  dull,  an  enema  is  of  little 
ser^ice,  as  it  will  not  extend  to  the  caecum,  and  purgatives  by 
the  mouth  are  indicated.  Sometimes  the  whole  colon,  or  the 
transverse  portion,  or,  w^hat  is  more  common,  tlie  sigmoid 
flexure  of  the  large  intestine,  becomes  distended  with  fsecal 
accumulations,  gi\Tng  rise  to  circumscribed  abdominal  enlarge- 
ment and  to  flatness  on  percussion  over  that  portion  of  the 
abdomen  which  corresponds  to  the  situation  of  the  intestines. 
Care  must  be  taken  not  to  confound  this  condition  with  an 
enlarged  Hver,  spleen,  tumors,  etc.  The  ^^ercussion  sound 
over  the  small  intestiaes,  unless  they  are  distended  with  gas, 
is  higher  pitched  and  less  amphoric  than  that  of  the  surround- 
ing large  intestiaes.  There  are  no  physical  signs  to  indicate 
the  abnormal  changes  which  occur  ia  this  position  of  the  ali- 
mentary canal,  except  an  increase  in  the  tymj)amtic  resonance 
which  exists  when  they  are  distended  with  gas. 

Liver. 

Our  diagnosis  in  any  case  of  hepatic  disease  rests  mainly 
on  the  size,  form,  and  position  of  the  liver  as  determined  by 
percussion  and  palpation.  The  first  step,  then,  in  studying 
the  physical  signs  indicative  of  disease  of  this  organ,  is  to 
become  familiar  with  its  normal  boundaries.  In  its  healthy 
state,  the  right  lobe  of  the  liver  occupies  the  right  hypochon- 


LIVER.  jgi 

drium,  lying  completely  in  tlie  hollow  formed  by  the  dia- 
phragm, rarely  descending  below  the  free  border  of  the  ribs, 
or  extending  upwards  above  the  fifth  intercostal  space ;  the 
left  lobe  reaches  across  to  the  left  of  the  median  line  an  inch 
or  more  (see  fig.  17). 

The  upper  boundary  of  the  organ  is  determined  by  percuss- 
ing with  moderate  force  from  the  right  nipple  downwards 
until  the  flatness  of  the  percussion  sound  indicates  that  a 
solid  organ  has  been  reached ;  draw  a  hne  at  this  point. 
Then  percuss  downwards  from  the  axilla,  and  from  a  point  a 
little  to  the  right  of  the  median  line  in  front,  in  the  same  man- 
ner, until  the  same  change  occurs  in  the  percussion  sound ;  a 
line  drawn  through  the  points  which  mark  the  change  in  the 
percussion  sound  along  these  hues  determines  the  upper 
boundary  of  the  lines  ;  and  it  wiU  be  found  generally  to  corre- 
spond to  the  base  of  the  ensiform  cartilage  on  the  median  line 
in  front  to  the  fifth  intercostal  space  on  the  line  of  the  right 
nipple,  to  the  seventh  rib  in  the  axillary  region,  and  to  the 
ninth  rib  in  the  dorsal  region.  The  lower  boundary  of  the 
organ  is  determined  by  percussing  downwards  from  the  hne 
of  flatness  already  determined,  and  noting  the  points  where 
the  tjTnpanitic  sounds  of  the  stomach  and  large  intestine  oc- 
cur, which  will  generally  be  found  to  correspond  anteriorly 
with  the  free  border  of  the  ribs,  and  to  a  point  three  inches 
below  the  ensiform  cartilage  on  the  median  hne  ;  laterally,  in 
the  axillary  region  to  the  tenth  intercostal  space,  and  poste- 
riorly, in  the  dorsal  region  to  the  twelfth  rib.  The  flatness  of 
the  left  lobe  usually  reaches  two  inches  to  the  left  of  the  me- 
dian line.  The  whole  margin  of  the  line,  except  where  it 
comes  in  contact  with  the  apex  of  the  heart  through  the  me- 
dium of  the  diaphragm,  may  thus  be  determined  and  marked 
out  on  the  surface.  The  vertical  measurements  will  be  found 
very  nearly  as  follows :  Three  inches  on  the  right  of  the  me- 
dian line  in  front ;  four  inches  on  a  Hne  with  the  right  nipple  ; 


132  PHYSICAL  DIAGNOSIS. 

four  and  one-lialf  inches  in  the  axillary  region;  and  four 
inches  posteriorly  in  the  dorsal  regions.  The  smooth  edge  of 
the  lower  margin  of  the  liver  in  health,  especially  in  thin  sub- 
jects, can  be  distinctly  felt  behind  the  free  border  of  the 
ribs. 

The  healthy  liver  in  its  normal  position  evidently  influences 
very  little  the  percussion  sound  over  the  soft  half  of  the  abdo- 
men, which,  as  has  already  been  stated,  when  the  organs 
there  situated  are  normal  and  empty,  yields  tympanitic  reso- 
nance from  immediately  below  the  margin  of  the  ribs  to  the 
pubes ;  if,  therefore,  the  percussion  sound  is  dull,  and  the  dul- 
ness  is  uninterrupted  to  the  margin  of  the  ribs  on  the  right 
side,  we  have  good  reason  for  believing  that  the  liver  is  the 
organ  diseased. 

The  normal  hoimdaries  of  the  liver  abeady  defined  may  be 
greatly  altered  without  any  abnormal  change  occurring  in  the 
organ  itself.  These  normal  changes,  imless  remembered,  may 
lead  to  errors  in  diagnosis.  Thus,  congenital  malformations, 
may  give  rise  to  an  increase  in  the  area  of  hepatic  dulness. 
An  accurate  history  of  the  patient,  however,  will  keep  us  from 
error  in  such  cases.  In  the  examination  of  children,  it  should 
also  be  remembered  that  the  liver  is  proportionally  larger 
than  in  adults. 

The  practice  of  tight  lacing  may  cause  displacement  and 
malformation  of  the  liver,  and  thus  give  rise  to  apparent 
hepatic  enlargement ;  the  marks  which  this  practice  leaves  on 
the  chest-walls  will  be  sufl&cient  to  attract  our  attention,  and 
so  prevent  mistake. 

Diseases  of  the  thoracic  organs  and  abnormal  conditions  of 
the  other  abdominal  viscera  sometimes  cause  displacement 
of  the  liver,  simulating  very  closely  hepatic  enlargement ; 
these  we  will  consider  under  the  head  of  differential  diagnosis 
of  diseases  of  the  liver. 


LIVER. 


133 


Variations  in  tlie  Size  of  the  Liver  in  Hepatic  Diseases. 

Variations  in  tlie  size  of  the  liver  occur  in  almost  every  dis- 
ease to  which  it  is  subject. 

It  is  increased  in  size,  in  fatty  liver,  in  luaxy  liver,  in  hydatid 
tumor,  in  abscess  of  liver,  in  congestion,  in  acute  hepatitis,  in  ob- 
struction of  the  bile  ducts,  and  in  cancer.  It  is  diminished  in  size 
in  cirrhosis  and  in  acute  atrophy.    Enlargements  of  the  liver 

Fig.  18. 


Diagram  representing  the  Different  Areas  occnpied  by  the  Liver  in  its  Various  Enlargements 
into  the  Abdominal  Cavitif. 

were  divided  by  Dr.  Bright  into  smooth  and  irregiilar.  Dr. 
Murcherson  has  divided  them  into  painless  and  painful  en- 
largements. Both  of  these  divisions,  it  seems  to  me,  have 
their  objections ;  and  in  giving  the  physical  signs  of  the  va- 
rious diseases  accompanied  by  enlargement  of  the  organ,  it  is 
hardly  practicable  to  adopt  either  of  them  exclusively. 


134  PHYSICAL  DIAGNOSIS. 

Fatty  Liver. — In  fatty  degeneration  of  the  liver  the  organ 
is  uniformly  enlarged  ;  there  are  no  circumscribed  bulgings  ; 
its  normal  shape  is  unaltered ;  there  is  no  expansion  of  the 
lower  ribs  ;  it  iiever  gives  rise  to  ascites,  and  it  is  not  attended 
by  any  visible  enlargement  of  the  superficial  veins.  On  palpa- 
tion below  the  margin  of  the  ribs  on  the  right  side,  and  in  the 
epigastrium,  a  soft  cushion-like  enlargement  is  readily  de- 
tected, extending  not  unfrequently  as  low  as  the  umbilicus ; 
its  outer  surface  is  smooth,  and  its  lower  margin  is  rounded, 
and  not  well  defined  ;  it  is  never  tende?^  on  pressure.  On  per- 
cussion there  is  flatness  over  the  surface  of  the  abdomen  cor- 
responding to  the  enlargement. 

Waxy  Liver. — In  waxy  or  amyloid  degeneration,  the  organ 
undergoes  greater  enlargement  than  in  fatty  degeneration  ;  it 
often  becomes  so  large  as  to  fill  the  whole  abdominal  ca\'ity ; 
its  growth  is  slow,  usually  extending  over  a  period  of  two  or 
three  years.  The  enlargement  is  uniform,  and  the  area  of 
hepatic  dulness  is  consequently  increased  on  percussion  in 
every  direction, — more,  however,  in  front  than  behind.  There 
is  often  on  inspection  a  visible  tumor  below  the  margin  of  the 
ribs,  but  there  is  no  bulging  of  the  ribs  themselves.  On  pal- 
pation, that  portion  of  the  organ  below  the  ribs  is  dense,  firm, 
and  resistant ;  the  outer  surface  is  smooth  ;  the  lower  margin 
is  sharp  and  well  defined.  Pain  and  tenderness  are  rarely 
present,  so  that  the  portion  of  the  organ  below  the  ribs,  as  in 
fatty  degeneration,  can  be  manipulated  without  giving  the 
patient  any  inconvenience.  "When  excessive,  it  is  almost  always 
accompanied  hy  ascites. 

Hydatid  Tumors  of  the  Liver. — Hydatid  cysts,  when  small 
or  deep-seated,  cannot  be  detected  by  physical  examination ;  but 
when  large  or  superficially  seated  hydatid  cysts  are  recognized 
by  abnormal  increase  in  the  area  of  hepatic  dulness, — the  out- 
line of  the  dulness  being  irregular, — and  by  the  globular  form 
of  the  enlargement  on  the  surface  of  the  organ.     Sometimes 


ABSCESS  OF  THE  LIVER  135 

these  cysts  are  so  large  as  to  cause  the  organ  to  fill  a  large 
portion  of  the  abdominal  and  encroach  on  the  right  pleural 
cavity ;  the  natural  form  of  the  organ  is  greatly  altered,  the 
enlargements  taking  place  more  in  one  direction  than  in 
another.  Sometimes  percussion  over  a  large  hydatid  cyst  -will 
give  rise  to  a  characteristic  vibration  known  as  hydatid  frem- 
itus ;  this  vibration  is  produced  by  the  impulse  of  the  smaller 
cysts  that  are  contained  in  a  large  one.  A  hydatid  liver 
encroaching  on  the  thoracic  cavity  gives  rise  to  flatness  on  per- 
cussion, and  absence  of  respiratory  sound  from  the  base  of  the 
chest  upwards  as  far  as  the  tumor  extends,  the  upper  boundary 
of  the  flatness  being  arched.  It  is  distinguished  from  pleu- 
ritic effusion  in  that  a  change  in  the  position  of  the  body 
does  not  change  the  line  of  percussion  duhiess.  On  palpation, 
sometimes  the  enlarged  j)ortion  below  the  ribs  has  an  elastic 
or  even  fluctuating  feel,  and  if  a  large  cyst  be  near  the  surface 
it  may  give  rise  to  a  sense  of  fluctuation ;  the  surface  over 
these  enlargements  is  smooth,  the  organ  is  not  tender  on  pres- 
sure, and  its  growth  is  slow. 

Abscess  of  the  Liver. — When  hepatic  abscesses  exist, 
from  w^hatever  cause,  it  depends  entirely  upon  their  situation 
whether  an  external  tumor  is  produced  or  not ;  if  the  abscess 
occupies  the  posterior  portion  of  the  right  lobe,  the  liver  is 
pushed  doT\Ti  so  that  its  margin  is  perceptible  below  the  free 
border  of  the  ribs,  and  the  flatness  on  the  right  side,  poste- 
riorly, extends  higher  than  natural.  When  an  abscess  is  su- 
perficial, and  is  pointing  externally,  a  distinct  tumor  is  felt 
below  the  ribs ;  and  there  is  always  more  or  less  bulging  of 
the  ribs  if  the  right  lobe  is  affected.  The  situation  of  the 
tumor  varies  according  as  the  right  or  left  lobe  is  affected ;  a 
tumor  arising  from  such  a  cause  is  easily  traced  as  connected 
with  the  liver,  of  w^hich  it  evidently  forms  a  part,  the  flatness 
on  percussion  being  continuous.  Sometimes  the  organ  is 
enormously  enlarged,  its  free  border  extending  below  the  um- 


136  PHYSICAL  DIAGNOSIS. 

bilicus,  tlie  surface  of  tlie  enlargement  being  smooth,  and 
usually  tender  on  pressure.  The  sensation  to  the  examiner 
on  making  light  pressure  will  be  soft  and  fluctuating,  or  that 
of  elastic  tenseness.  In  some  rare  instances,  abscesses  pro- 
duce an  uneven  or  lobulated  condition  of  the  surface ;  under 
such  circumstances  it  may  be  mistaken  for  cancer,  unless  the 
rational  symptoms  and  history  of  the  case  be  included  in  the 
elements  of  diagnosis.  The  enlargement  goes  on  rapidly. 
"With  a  correct  history  of  the  case,  the  diagnosis  is  easily  made. 

Congestion  of  the  Liver. — The  most  simple  form  of  he- 
patic enlargement  is  that  which  results  from  congestion. 
When  the  liver  is  thus  loaded  with  blood,  a  slight  fulness  is 
perceptible  on  the  right  side.  On  palpation,  the  space  imme- 
diately below  the  ribs  is  occupied  by  a  smooth,  hard,  resisting 
enlargement  corresponding  to  the  natural  shape  of  the  hver, 
which  is  not  usually  tender  on  pressui'e.  There  is  no  well-de- 
fined tumor. 

On  j)ercussion  a  flat  sound  is  elicited,  an  inch  or  two  below 
the  margin  of  the  ribs,  on  the  right  side. 

Obstruction  of  the  Bile  Ducts. — An  enlargement  of  the 
liver  similar  to  the  one  just  noticed  occurs,  when  from  any  cause 
there  is  obstruction  in  the  biliary  ducts,  and  an  accumulation 
of  bile  takes  place  in  the  liver.  Sometimes  when  this  occurs, 
in  addition  to  the  general  enlargement  detected  by  the  slight 
uniform  increase  in  the  normal  area  of  hepatic  dulness,  a 
globular  projection  is  detected  at  a  point  corresponding  to  the 
transvei^se  fissure  of  the  liver,  with  the  elastic  feel  of  deep- 
seated  fluid  ;  this  tumor  is  the  distended  gall  bladder. 

Acute  Hepatitis. — The  physical  signs  of  acute  hepatitis 
do  not  differ  materially  from  those  of  simple  congestion,  ex- 
cept in  the  excessive  tenderness  that  exists  on  pressure  over 
that  portion  of  the  organ  which  descends  below  the  ribs. 

Cancer  of  the  Liver. — ^In  most  cases  of  cancer,  the  diag- 
nosis is  easily  made. 


DECREASE  IN  SIZE  OF  LIVER.  I37 

On  Percussion  the  areca  of  the  hepatic  dulness  is  always 
increased,  sometimes  extremely  so;  the  organ  is  found  to 
occupy  the  greater  portion  of  the  epigastrium,  extending  be- 
yond the  median  line,  into  the  left  hypochondiium,  pushing  the 
diaphragm  upwards,  and  often  descending  below  the  ribs,  to 
the  crest  of  the  ilium. 

On  Palpation,  u-regular  nodules  of  various  size  are  dis- 
tincly  felt  through  the  abdominal  waUs,  projecting  from  the 
surface  of  that  portion  of  the  enlarged  organ  which  is  below 
the  free  border  of  the  ribs ;  these  prominences  are  usually 
harder  than  the  surrounding  hepatic  tissue,  and  there  is  more 
or  less  tenderness  on  pressure  over  them.  Cancer  of  the  hver 
may  or  may  not  be  accompanied  by  ascites. 

Occasionally  the  surface  of  the  liver  in  cancer  is  perfectly 
smooth,  and  in  such  cases  you  wiU  be  unable  to  detect  the 
disease  by  the  physical  signs. 

Decrease  in  the  size  of  the  Liver, 

The  Hver  is  diminished  in  size  in  cirrhosis,  and  in  acute 
atrophy. 

Cirrhosis  of  the  Liver. — ^In  fully  developed  cases  of  cir- 
rhosis of  the  liver,  the  organ  is  always  diminished  in  size,  and 
there  is  more  or  less  abdominal  dropsy.  The  only  evidence 
of  this  disease  furnished  by  inspection  is  a  visible  enlarge- 
ment of  the  superficial  veins. 

Percussion. — The  area  of  the  normal  hepatic  flatness  is 
diminished ;  its  limits  are  determined  as  follows :  If  the  ab- 
dominal cavity  is  distended  with  dropsical  accumulations,  the 
patient  should  be  placed  partly  on  the  left  side,  so  that  the 
fluid  will  gravitate  from  the  hepatic  region ;  the  percussion 
flatness  then,  instead  of  extending  to  the  fi-ee  border  of  the 
ribs,  will  often  give  place  to  tympanitic  resonance,  an  inch  or 
more  above  their  free  margin,  and  instead,  also,  of  extending 
across  the  median  line  into  the  left  hypochondrium,  will  rarely 


138  PHYSICAL  DIAGNOSIS. 

reacli  that  line ;  while  the  vertical  measurement  of  hepatic 
dulness  on  a  line  with  the  right  nipple  does  not  often  exceed 
two  and  a  half  inches. 

Palpation. — By  firm  pressure  with  the  ends  of  the  fingers 
ujDwards,  httle  nodules  will  often  be  felt  on  the  under  surface 
of  the  organ ;  sometimes  when  the  distension  of  the  abdomen 
from  dropsical  accumulation  has  been  very  great,  we  can  get 
no  information  by  palpation  until  after  the  performance  of 
paracentesis. 

Atrophy  of  the  Liver. — The  only  physical  sign  of  atrophy 
of  the  Hver  is  obtained  from  rapid  diminution  in  the  size  of 
the  organ,  as  ascertained  by  percussion,  its  surface  remaining 
smooth  ;  the  diminution  never  being  accompanied  with  ascites. 

Differential  Diagnosis  of  Diseases  of  the  lAver, 

The  sources  which  may  lead  to  error  in  the  conclusion  that 
the  liver  is  the  seat  of  disease  when  it  is  not,  are,  fsecal  ac- 
cumulations in  the  ascending  and  transverse  colon  ;  enlarge- 
ment of  the  right  kidney ;  diseases  of  the  stomach ;  dis- 
placement of  the  liver  by  disease  in  the  right  side  of  the 
chest;  enlargement  of  the  spleen;  tumors  of  the  omentum, 
and  ovarian  tumors. 

FsBcal  Accumulations. — To  distinguish  these  accumula- 
tions from  enlargement  of  the  liver,  by  physical  examination, 
is  always  difficult  and  sometimes  impossible  ;  they  give  rise  to 
a  distinct  tumor  below  the  border  of  the  ribs  which  by  per- 
cussion and  palpation  seem  to  be  continuous  and  connected 
with  the  liver.  The  characteristic  feel  of  these  faecal  en- 
largements aheady  referred  to  wiU  assist  you  somewhat. 
The  differential  diagnosis  sometimes,  however,  can  only  be 
made  after  making  trial  of  remedies  which  by  acting  freely  on 
the  bowels  remove  the  accumulations,  and  cause  the  disap- 
pearance of  the  supposed  hepatic  enlargement. 


SPLEEN. 


139 


Disease  of  the  Right  Kidney.— The  right  kidney  some- 
times enlarges  in  such  a  manner  as  to  present  itself  as  a 
tumor,  extending  from  the  under  surface  of  the  right  lobe  of 
the  Hver.  If  it  has  attained  considerable  size,  it  may  there- 
fore seem  to  be  continuous  with  the  Hver  as  a  growth  from  its 
substance.  It  may  be  distinguished  from  the  hver  by  care- 
fully examining  its  relation  to  the  ribs  ;  as  the  patient  lies  on 
his  back,  the  enlargement,  instead  of  passing  up  under  the 
ribs,  dips  down,  so  as  to  allow  the  finger  to  pass  vertically 
between  the  tumor  and  the  ribs. 

Diseases  of  the  Stomach. — The  only  disease  of  the  stom- 
ach which  we  are  likely  to  confound  with  enlargement  of  the 
liver  is  cancer.  It  can,  however,  usually  be  readily  distin- 
guished from  it  by  the  tympanitic  quaUty  of  the  percussion 
sound  over  the  cancerous  mass,  and  by  the  mobihty  of  the 
supposed  enlargement. 

Displacements  of  the  Liver  downwards  from  extensive 
pleuritic  effusion,  and  from  pneumo-thorax,  are  recognized 
by  the  presence  of  the  physical  signs  which  indicate  these 
thoracic  diseases. 

Enlargement  of  the  Spleen  and  Ovarian  Tumors  are 
distinguished  from  enlargements  of  the  liver  by  the  shape  of 
the  tumor,  and  by  the  continuous  and  increasing  flatness  of 
the  percussion  sound  as  we  pass  towards  the  normal  position 
of  these  organs. 

Spleen, 

The  spleen,  from  the  obscurity  which  involves  its  natu- 
ral function,  so  that  its  affections  usually  give  rise  to  but 
negative  general  symptoms,  and  from  its  comparatively  iso- 
lated situation,  often  presents  greater  difficulties  in  the 
diagnosis  of  its  morbid  conditions  than  is  the  case  with  any 
other  abdommal  organ.  In  health  this  organ  occupies  the 
upper  portion  of  the  left  hypochondriac  region,  its  lower 


140 


PHYSICAL  DIAGNOSIS. 


border  touclies  the  left  kidney,  while  its  convex  surface  occu- 
pies the  concavity  of  the  diaphragm.  It  is  bounded  super- 
ficially, above  by  the  lower  border  of  the  ninth  rib  ;  anteriorly 
by  the  stomach  and  left  colon ;  and  inferiorly  by  the  free 
margins  of  the  ribs.  It  is  about  four  inches  long  and  three 
wide.  In  its  healthy  condition,  inspection  and  palpation  fur- 
nish only  negative  results. 

Percussion. — To  determine  the  boundaries  of  the  spleen  by 
percussion,  it  is  necessary  that  the  patient  should  lie  on  the 

Fig.  19. 


Diagram  representing  the  different  Areas  occupied  by  the  Spleen  in  its  various  Enlargements 
into  the  Abdominal  Cavity. — Beigut. 

right  side.  Its  anterior  border  is  readily  determined  by  the 
tympanitic  resonance  of  the  stomach  and  intestines.  Infe- 
riorly, where  the  organ  comes  in  contact  with  the  kidney,  it  is 
difficult  and  often  impossible  to  determine  its  boundary.  Its 
superior  border  corresponds  to  the  line  which  marks  the 
change  from  flatness  to  pulmonary  resonance. 
In  disease,  the  s^Dleen  may  be  increased  or  diminished  in 


SPLEEN.  141 

size.  "We  are  rarely,  if  ever,  able  to  recognize  atrophy  of  the 
spleen  during  life.  In  most  cases  of  splenic  disease  there  is 
neither  pain  nor  tenderness.  The  only  reliable  physical  signs 
of  disease  of  the  organ  are  connected  with  its  enlargements. 
The  tumor  produced  by  the  enlargement  of  the  organ  can 
scarcely  be  overlooked.  Its  characteristics  are  a  smooth, 
oblong,  solid  heap,  felt  immediately  beneath  the  integuments, 
extending  from  under  the  ribs  on  the  left  side,  a  httle  behind 
the  origin  of  the  cartilages,  after  advancing  to  the  median 
line  in  one  direction,  and  descending  to  the  crest  of  the  ilium 
in  the  other,  fiUing  the  left  lumbar  region  at  its  upper  part. 
This  tumor  is  usually  movable,  rounded  at  its  upper  portion, 
and  presenting  an  edge  more  or  less  sharp  in  front,  where  it 
is  often  notched  and  fissured. 

The  principal  tumors  which  may  be  mistaken  for  an  en- 
larged spleen  are,  chronic  abscess  of  the  integuments,  cancer 
of  the  stomach,  enlargement  of  the  left  lobe  of  the  liver,  dis- 
eased omentum,  fascal  accumulation  in  the  colon,  disease  of 
the  left  kidney,  and  ovarian  disease. 

Chronic  Abscess  in  the  Abdominal  Wall  sometimes  oc- 
curs precisely  in  the  situation  of  an  enlarged  spleen,  but  it  is 
easily  distinguishable  from  it,  by  the  superficial  character  of 
the  sweUing,  and  by  its  being  too  soft  to  belong  to  an  internal 
viscus. 

Cancerous  Deposit  in  the  cardiac  extremity  of  the  stomach 
sometimes  gives  rise  to  a  tumor,  which,  from  its  being  deeper 
than  the  abdominal  walls,  and  descendmg  from  the  margm  of 
the  ribs,  might  be  mistaken  for  an  enlarged  spleen.  One  of 
the  best  distinctive  marks  wiU  be  found  in  the  sound  elicited 
by  forcible  percussion,  wliich,  when  the  stomach  is  diseased, 
has  more  or  less  of  a  tympanitic  resonance,  while  the  tumor 
is  harder  to  the  feel  than  an  enlarged  spleen. 

Enlarged  Left  Lobe  of  the  Liver  is  easily  distinguished 
from  enlarged  spleen ;  for  the  margin  of  the  tumor  can  be 


142  PHYSICAL  DIAGNOSIS. 

traced  running  towards  the  right,  and  not  towards  the  left,  as 
is  the  case  with  enlarged  spleen. 

Cancerous  and  Tubercular  Enlargements  of  the  omentum 
are  distinguished  from  an  enlarged  spleen  by  the  fact,  that 
they  extend  across  the  abdomen,  and  cannot  be  traced  back- 
wards ;  they  do  not  ascend  behind  the  ribs,  and  are  rough, 
hard,  and  uneven. 

Faecal  Accumulation  in  the  intestines  is  a  source  of  very 
gi'eat  difficulty  in  this  diagnosis,  for  when  it  takes  place  in  the 
descending  colon,  at  the  sigmoid  flexure,  the  enlargement 
assumes  very  nearly  the  situation  of  an  enlarged  spleen,  and 
is  scarcely  to  be  distinguished  from  it,  except  by  its  peculiar 
feel,  by  its  history,  and  by  the  results  of  cathartics ;  nor  must 
we  without  the  most  persevering  employment  of  purgatives 
and  enemata  conclude  that  the  intestines  have  been  emptied. 

The  Left  Kidney  sometimes  enlarges  towards  the  left  hy- 
pochondrium,  and  joresents  a  tumor  very  nearly  in  the  situa- 
tion of  an  enlarged  spleen ;  but  by  tracing  it  back  towards 
the  loins,  we  shall  find  that  its  chief  bulk  is  situated  much 
farther  back,  and  that  it  is  much  more  fixed,  so  that  if  the 
patient  is  placed  on  his  hands  and  knees,  it  does  not  fall  for- 
wards. By  observing  the  rules  for  the  diagnosis  of  ovarian 
tumors,  we  shall  easily  distiuguish  them  from  enlarged  spleen 
(Bright). 


LESSONXV. 

Physical  Sfff7is  of  t?ie  Abnormal  Changes  in  the  different 
Abdominal  Organs— Continued. 

Kidneys,  Bladder,  Uterus,   Ovaries,  Aneurisms, 
Omentum,  Mesentery. 

Kidneys.— The  kidneys  in  health  are  situated  in  the  kim- 
bar  regions,  as  shown  in  fig.  2,  in  the  space  corresponding  to 
the  two  lower  dorsal,  and  the  two  upper  lumbar  vertebrge ; 
the  right  is  a  little  lower  than  the  left.  Superficially,  they  ex- 
tend from  the  eleventh  rib  to  the  crest  of  the  ilium.  The 
right  is  bounded,  above  by  the  posterior  and  inferior  portion 
of  the  right  lobe  of  the  liver ;  below  by  the  coecum  ;  anteriorly 
by  the  ascending  colon,  and  posteriorly  by  the  diaphragm  and 
quadratus  lumborum.  The  left  is  bounded,  above  by  the 
spleen  ;  anteriorly  and  inferiorly  by  the  colon,  and  posteriorly 
by  the  diaphragm  and  quadratus  lumborum. 

In  disease,  the  kidneys  may  be  increased  or  diminished  in 
size.  Atrophy,  or  diminution  in  the  size  of  the  kidneys,  can 
rarely  be  determined  by  physical  examination,  so  that  en- 
largements are  the  only  conditions  to  which  physical  explora- 
tion is  applicable.  The  kidneys  may  be  enlarged  from  calculi 
pyelitis,  which  sometimes  converts  the  kidneys  into  a  bag  of 
pus ;  cancerous  and  tubercular  deposits,  hydatid  cysts,  and 
simple  distension,  the  result  of  obstruction  of  a  ureter.  A 
tumor  is  also  sometimes  developed  at  the  ujjper  border  of  a 
kidney,  from  disease  of  the  supra-renal  capsule. 

Inspection  rarely  furnishes  any  evidence  of  enlargement  of 
a  kidney ;  and,  not  unfrequently,  after  examining  the  lumbar 


144  PHYSICAL  DIAGNOSIS. 

regions  by  ^jaZ^a^zow  with  great  care,  and  by  careful  compar- 
ison of  tlie  two  sides,  we  are  unable  to  recognize  any  change 
in  the  size  of  these  organs  ;  but  as  soon  as  we  place  our 
hand  anteriorly,  and  press  firmly  towards  the  normal  position 
of  the  kidney,  a  tumor  is  felt ;  then,  by  pressing  the  tumor 
backwards,  our  other  hand  resting  on  the  lumbar  region  of  the 
same  side,  we  at  once  determine  that  this  tumor  has  its  origin 
in  the  kidney.  The  part  of  the  abdomen  in  which  a  renal 
tumor  is  felt,  will  vary,  according  to  the  nature  of  the  disease 
and  the  portion  of  the  kidney  involved. 

Percussion. — In  percussing  the  kidneys,  the  patient  should 
be  placed  on  the  abdomen  and  chest,  which  posture  wiU  allow 
fluid  accumulations  in  the  abdominal  cavity  to  gravitate  for- 
wards, and  the  intestines  to  float  upwards.  The  external 
margin  of  the  kidneys  can  then  be  readily  determined  by  the 
tympanitic  note  of  the  intestines  around  their  external  cir- 
cumference, except  where  they  are  in  relation  to  the  vertebrae. 
In  health,  the  outhnes  of  the  renal  dulness  will  correspond  to 
the  limits  abeady  given.  Any  enlargement  of  these  organs 
will  cause  a  corresponding  increase  in  the  area  of  renal  dul- 
ness ;  but  we  cannot  by  physical  examination  estabhsh  the 
exact  nature  of  the  disease  to  which  the  increase  in  the  organ 
is  due. 

The  sources  of  error  in  the  diagnosis  of  enlargements  of 
the  kidneys  vary,  according  as  the  right  or  left  kidney  is  the 
seat  of  disease. 

Enlargement  of  the  right  kidney  may  be  mistaken  for  an 
enlargement  of  the  right  lobe  of  the  liver,  for  cancer  of  the 
pyloric  orifice  of  the  stomach,  for  faecal  distension  of  the 
colon,  and  for  enlargement  of  the  right  ovary.  The  rules  for 
distinguishing  it  from  each  of  these  have  been  already  given 
in  the  previous  section,  as  likewise,  for  distinguishing  enlarge- 
ments of  the  left  kidney  from  enlargement  of  the  spleen,  the 
left  ovary,  and  from  faecal  distension  of  the  descending  colon. 


UTERUS.  145 

Movable  Kidney. — This  is  not  properly  a  disease,  but  a 
peculiarity  of  structure  in  certain  individuals.  The  attach- 
ments of  the  kidneys,  or  more  generally  of  only  one  kidney, 
are  so  loose  that  the  organ  can  be  displaced,  either  vertically 
or  laterally,  to  a  considerable  degree,  and  this  may  so  ap- 
proach the  anterior  abdominal  walls,  as  to  be  readily  felt 
through  them.  It  can  be  detected  by  drawing  up  the  feet, 
and  retracting  the  abdomen,  then  grasping  the  tumor  with  the 
palm  of  the  hand.  It  has  a  smooth  rounded  feel,  and  differs 
from  mesenteric  tumors  or  fi3ecal  accumulations  in  whoUy  dis- 
appearing on  gentle  pressure  into  the  abdominal  cavity,  so 
that  it  can  no  longer  be  distinguished. 

Bladder. — ^When  the  bladder  is  empty,  its  position  cannot 
be  determined  by  physical  exploration  ;  it  can  only  be  detected 
when  it  is  distended,  and  rises  above  the  pubes  ;  when  this  is 
the  case  a  tumor  is  visible  in  the  hypogastric  region,  which  on 
palpation  is  smooth  and  oval.  Its  circular  margin  is  easily 
made  out  by  observing  the  tympanitic  sound  of  the  intestines 
on  the  one  hand,  and  the  dull  sound  produced  by  the  bladder 
on  the  other.  In  infants,  the  bladder  is  not  as  deep  in  the 
pelvis  as  in  adults  ;  consequently  a  smaller  quantity  of  urine 
in  the  bladder  can  be  recognized.  A  distended  bladder  can 
only  be  mistaken  in  the  female  for  a  gravid  uterus,  or  a 
uterine  tumor  ;  the  use  of  a  catheter  removes  all  doubts. 

Uterus. — The  unimpregnated  uterus  in  its  normal  state  is 
situated  in  the  lower  part  of  the  hypogastrium,  and  is  inacces- 
sible to  the  touch,  externally,  or  to  percusion,  but  when  nor- 
mally developed  by  impregnation,  or  abnormally  by  disease, 
palpation,  percussion,  and  auscultation  furnish  us  with  impor- 
tant information. 

In  pregnancy,  at  the  end  of  the  second  month,  a  dull  sound 
on  percussion,  just  above  the  pubes,  indicates  the  develop- 
ment of  the  uterus  ;  later,  as  the  uterus  increases  in  volume, 
and  rises  into  the  abdomen,  we  are  able  by  the  oval  tumor  felt 


146  PHYSICAL  DIAGNOSIS. 

in  tlie  liypogastrmm,  and  by  the  circumscribed  area  of  dul- 
ness,  corresponding  to  the  situation  of  the  tumor,  to  estabhsh 
strong  presumptive  evidence  of  pregnancy.  The  presumption 
becomes  strengthened,  if  the  area  of  the  dulness  increases 
with  the  regularity  proper  to  gestation.  But  percussion  and 
palpation  are  insufficient  to  determine  whether  the  develop- 
ment of  the  uterus  is  due  to  pregnancy,  or  to  some  morbid 
deposit  in  its  walls  or  cavity,  as  fibrous  tumors,  etc. 

After  the  end  of  the  fifth  month,  the  evidence  furnished  by 
both  these  methods  is  inferior  to  auscultation. 

Rules  for  Performing  Uterine  Auscultation. — The  female 
should  be  placed  on  her  back  with  her  thighs  slightly  flexed, 
so  as  to  relax  the  abdominal  muscles ;  sometimes  it  is  well  to 
incline  the  body  from  one  side  to  the  other,  or  forwards  so  as 
to  withdraw  the  pressure  of  the  uterus  from  the  pelvic 
arteries.  The  abdomen  should  be  uncovered,  as  the  sounds 
to  be  examined  are  of  slight  intensity,  and  very  circumscribed ; 
then-  study  demands  close  attention  and  perfect  silence.  The 
stethoscope  is  always  to  be  preferred,  and  the  uterine  tumor 
should  be  auscultated  successively  at  different  points. 

After  the  fourth  month  of  gestation,  if  the  uterus  contains 
a  hving  foetus,  we  may  hear  three  distinct  sounds, — the  Pla- 
cental Bruit,  which  is  evidently  connected  wdth  the  circulation 
of  the  mother ;  the  Foetal  Heart,  and  the  Funic  Souffle,  which 
are  connected  with  the  circulation  of  the  foetus. 

Placental  Bruit. — Tliis  sound  is  single,  intermitting,  and  in 
character,  is  a  combination  of  the  blowing  and  hissing  sounds. 
It  increases  in  intensity  up  to  the  period  of  labor.  It  is  be- 
lieved to  depend  upon  the  rapid  passage  of  blood  from  the 
arteries  into  the  distended  venous  sinuses.  It  is  synchronous 
with  the  maternal  pulse,  is  subject  to  the  same  variations,  and 
is  always  heard  before  the  pulsation  of  the  foetal  heart. 

Tlie  Area  over  which  it  is  audible  varies  ;  in  some  instances 
it  is  limited  to  a  single  point,  in  others  it  is  audible  over  a 


UTERINE  SOUNDS.  l^j 

surface  of  three  or  four  inclies,  and  in  a  few  it  is  heard  over 
tlie  whole  uterine  tumor,  although  there  will  always  be  one 
spot  of  greatest  intensity,  corresponding  to  the  placental  at- 
tachment.   It  is  also  intensified  by  uterine  contractions. 

During  the  first  haK  of  pregnancy  it  is  usually  heard  with 
greatest  intensity  in  the  median  hue,  a  little  above  the  pubes  ; 
after  the  fifth  month  at  the  lateral  and  inferior  borders  of  the 
uterus  ;  and  next  in  order  of  time  it  will  be  heard  at  the 
fundus. 

This  sound  may  be  confounded  with  the  respiratory  mur- 
mur of  the  mother,  and  with  intestinal  murmurs ;  these  mur- 
murs, however,  are  not  synchronous  with  the  pulse  of  the 
mother,  and  if  this  fact  is  remembered,  there  will  be  hfctle 
difficulty  in  distinguishing  them.  As  a  proof  of  pregnancy, 
placental  bruit  is  not  positive,  as  it  is  sometimes  heard  in  con- 
nection with  uterine  and  ovarian  tumors.  It  does  not  prove 
that  the  foetus  is  alive,  for  it  is  heard  for  a  long  time  after  its 
death.  Its  negative  e^^dence  is  of  less  value,  for  if  the  pla- 
centa is  attached  posteriorly,  we  may  not  be  able  to  hear  it, 
although  pregnancy  exist. 

Funic  Souffle. — This  sound  is  usually  heard  at  a  point  quite 
remote  from  the  placental  bruit ;  it  is  short,  feeble,  and  blow- 
ing in  character,  and  corresponds  in  pregnancy  with  the  foetal 
pulsation.  It  is  supposed  to  depend  upon  obstruction  to  the 
transmission  of  blood  through  the  umbilical  arteries,  as  from 
twirling  or  knotting  of  the  funis,  or  fi'om  external  pressure. 
It  is  not  a  constant,  nor  even  a  frequent  sound,  the  conditions 
of  its  production  being  rarely  met  with. 

Foetal  Heart  Sound. — This  sound  consists  of  a  succession 
of  short,  rapid,  double  pulsations,  varying  in  frequency  from 
120  to  140  per  minute.  The  first  sound  is  short,  feeble,  and 
obscure,  while  the  second,  the  one  we  usually  hear,  is  loud  and 
distinct,  and  may  be  heard  generally  over  the  body  and  limbs 
of  the  child.     This  sound  has  been  aptly  compared  to  the 


148  PHYSICAL  DIAGNOSIS. 

ticking  of  a  watcli  wrapped  in  a  napkin,  and  is  usually  earKest 
heard  at  tlie  middle  of  the  fourth  month.  The  frequency  of 
the  pulsations  do  not  vary  with  the  age  of  the  foetus. 

The  extent  over  which  the  foetal  heart  sound  is  audible 
varies;  usually  it  is  transmitted  over  a  space  three  or  four 
inches  square.  The  location  of  the  sound  is  determined  by 
the  position  of  the  foetus.  It  has  been  stated  that  by  drawing 
a  horizontal  line  and  dividing  the  uterus  iato  equal  parts,  that 
whenever  the  maximum  of  iatensity  of  the  sound  is  below  this 
line,  it  is  a  vertex  presentation  ;  when  above,  it  is  a  breach  ; 
also,  when  the  foetal  pulsations  are  heard  low  down  in  front  on 
the  left  side,  that  the  foetus  is  in  the  first  position  ;  if  heard 
below  and  in  front  on  the  right  side,  it  is  in  the  second 
position. 

Twin  pregnancy  may  sometimes  be  determined  by  the  pres- 
ence of  heart  sounds  heard  at  distant  points  over  the  uterine 
tumor,  and  by  the  absence  of  synchronism  in  the  two  pulsa- 
tions. The  sources  of  deception  in  exploring  for  the  foetal 
heart  sound  are  the  Hability  of  confounding  the  pulsation  of  the 
iliac  arteries  or  abdominal  aorta  of  the  mother  with  it ;  in  most 
cases  their  situation,  comparative  frequency,  and  absence  of 
double  pulsation  will  determine  their  character.  But  a  diffi- 
culty will  sometimes  occur  in  discriminating  between  them 
when  the  natural  pulse  is  very  much  increased  in  frequency 
and  the  foetal  diminished.  Under  such  circumstances  we 
must  be  guided  by  the  character  of  the  sound,  and  whether  it 
is  or  is  not  synchronous  with  the  radial  pulse. 

Again,  in  the  early  stage  of  pregnancy,  the  intensity  and 
impulse  of  the  maternal  pulsation  may  render  the  feeble  foetal 
sound  inaudible  ;  this  difficulty  may  be  obviated  by  removing 
the  pressure  of  the  uterine  tumor  upon  the  subjacent  arte- 
ries, which  can  be  done  by  changing  the  posture  of  the  mother. 

During  labor,  our  examinations  should  be  made  in  the  inter- 
val between  uterine  contractions. 


OVARIES.  149 

In  protracted  labors  auscultatioii  is  of  value  in  indicating  to 
us  the  time  for  manual  or  instrumental  interference  to  save 
the  life  of  the  child.  The  indications  of  danger  to  the  child 
are  feebleness,  or  excessive  frequency  of  the  foetal  pulsation ; 
irregularity  in  its  rhythm ;  absence  of  the  second  sound ;  its 
complete  cessation  during  uterine  contraction,  and  the  slow- 
ness of  its  return  in  the  interval.  Irregularity  and  feebleness 
are  the  most  threatening  to  the  life  of  the  child.  "When  the 
sound  of  the  foetal  heart  is  heard  it  is  a  positive  proof  of  preg- 
nancy ;  but  its  absence  is  not  always  proof  that  pregnancy 
does  not  exist,  for  the  foetus  may  be  dead,  and  in  some  rare 
cases  the  sounds  may  exist  and  be  quite  inaudible  for  a  time, 
and  then  appear.  This  phenomenon  is  not  easily  accounted 
for. 

Tumors  of  the  Uterus,  whether  developed  on  its  surface, 
in  its  walls,  or  within  its  cavity,  give  rise  to  enlargement  of 
the  organ,  which  causes  it  to  occupy  a  position  coiTesponding 
to  that  occupied  by  a  gravid  uterus.  The  position  and  extent 
of  these  enlargements  are  determined  in  the  same  manner  as 
we  determine  the  size  and  position  of  the  uterus  in  pregnancy. 
Deposits  in  its  walls  or  on  its  sui-face  give  rise  to  nodules 
which  feel  through  the  abdominal  walls  like  hard  balls,  vary- 
ing in  size  and  shape,  seldom  occurring  singly.  The  whole 
mass  can  usually  be  moved  fi'om  one  side  to  the  other.  The 
connection  of  these  tumors  with  the  uterus,  as  determined  by 
the  uterine  sound,  leave  little  doubt  as  to  their  true  character, 
and  by  this  means  we  readily  distmguish  them  from  all  other 
abdominal  tumors. 

Ovaries.— The  ovaries  in  a  normal  state  lie  in  the  pelvic 
cavity,  and  their  position  cannot  be  determined  by  physical 
exploration ;  but  when  they  become  the  seat  of  those  forms  of 
disease  which  cause  their  enlargement,  and  have  attained  such 
dimensions  that  there  is  no  longer  room  for  them  in  the  pelvic 
cavity,  they  ascend  above  the  brim  of  the  pelvis,  and  occupy 


150 


PHYSICAL  DIAGNOSIS. 


more  or  less  space  among  tlie  abdominal  organs.  As  they 
pass  out  of  the  pelvis,  they  are  first  noticed  in  the  right  or  left 
iliac  region,  according  as  the  right  or  left  ovary  is  affected, 
and  they  are  then  recognized  as  ovarian  tumors.  After,  be- 
fore these  ovarian  enlargements  have  attained  sufficient  size 
to  attract  the  attention  of  the  patient,  they  will  have  reached 
a  central  position  in  the  abdominal  cavity.  They  are  of  more 
frequent  occurrence  than  aU  other  forms  of  abdominal  tumors ; 

Fig,  20. 


Diagram  showing  the  Gradtutl  Enlargement  of  a  Tumor  of  the  Right  Ovary  till  it  fills  a  large 
portion  of  the  Abdominal  Cavity  forcing  the  Intestines  into  the  Lumlar  Regions.— 'Qmani. 

and  their  existence  is  determined  almost  exclusively  by  the 
physical  signs  which  they  furnish. 

Inspection. — In  the  early  part  of  their  development  an  un- 
even projection  or  prominence  of  one  part  of  the  abdomen 
will  disclose  the  seat  of  the  tumor,  occupying  usually  the  iliac 
or  lumbar  region  of  one  side,  and  extending  upwards  to  or  be- 
yond the  umbilicus ;  while  in  more  advanced  cases  no  inequal- 


OVARIES.  251 

ity  will  be  visible,  but  the  rounded  form  of  tlie  abdomen,  while 
the  patient  lies  on  her  back,  offers  a  strong  conti'ast  to  the 
flattened  oyal  appearance  of  ascites,  or  the  central  rounded 
form  of  a  uterus  distended  with  pregnancy. 

Palpation, — Ovarian  tumors  when  small  have  a  firm,  elastic 
feel,  but  when  large  they  are  soft  and  fluctuating.  In  some 
cases,  by  passing  the  hand  gently  over  the  abdomen,  the  ex- 
tent of  the  tumor  will  be  readily  appreciated.  At  other  times 
the  limits  of  the  tumor  cannot  be  ascertained  by  gentle  palpa- 
tion, for  it  occupies  the  whole  of  the  abdomen  excej)t  the  con- 
cavity of  the  diaphragm.  In  such  cases,  by  making  firm,  but 
not  forcible  pressure  on  various  parts  of  the  abdomen,  we 
often  detect  at  once  a  general  sense  of  fluctuation,  and  ascer- 
tain inequalities  which  neither  the  eye  nor  the  hand  when 
passed  gently  over  the  surface  will  enable  us  to  detect ;  and 
sometimes  if  the  abdomen  is  not  tense,  we  can  feel  masses 
which  convey  the  impression  of  more  or  less  flattened  or 
spherical  bodies  attached  to  the  inside  of  a  fluctuating  tumor. 
In  some  cases  the  sense  of  fluctuation  is  very  indistinct ;  in 
others,  it  is  even  more  evident  than  in  cases  of  extensive 
ascites. 

Percussion. — The  sound  elicited  on  percussion  is  flat  over 
that  portion  of  the  abdomen  where  the  tumor  comes  in  con- 
tact ^ith  the  interior  surface  of  the  abdominal  wall ;  while  at 
the  sides  and  above  where  the  intestines  have  been  pushed 
aside  and  upwards  by  the  tumor,  the  percussion  sound  will  be 
tympanitic  ;  by  this  change  in  the  percussion  sound  we  are 
enabled  to  mark  out  the  boundaries  of  the  tumor. 

Differential  Diagnosis. — Ovarian  tumors  may  be  confounded 
in  their  diagnosis  with  uterine  enlargements,  as  pregnancy, 
fibroid  tumors  of  the  uterus,  etc.,  ascites,  hydatids  of  the  omen- 
tum, /cecal  accumulations  in  the  intestines,  and  enlargements  of  the 
liver,  spleen,  and  Iddneys. 

They  are  distinguished  from  pregnancy  by  a  stethoscopic 


152  PHYSICAL  DIAGNOSIS. 

examination  of  the  tumor,  "wliicli  reveals  in  tlie  one  case  the 
sounds  of  tlie  foetal  heart,  and  in  the  other  their  absence. 
They  are  distinguished  from  uterine  tumors  by  theu'  consist- 
ence, by  their  outline,  by  the  difference  in  then:  connection 
and  relative  position  to  the  uterus,  and  by  the  fact  that  in 
uterine  tumors  the  cavity  of  the  uterus  as  determined  by  the 
uterine  sound  is  always  elongated.  The  diagnosis  between 
ovarian  and  abdominal  dropsy  is  made,  First,  by  observing 
the  difference  in  the  shape  of  the  abdomen  when  the  patient 
lies  on  her  back;  ovarian  tumors  project  forwards  in.  the 
centre,  while  in  ascites  the  abdominal  enlargement  is  uniform. 
Second,  in  ovarian  tumors  the  percussion  sound  is  dull,  as 
high  as  the  tumor  extends,  while  at  the  same  time  there  will 
be  tympanitic  resonance  in  the  most  depending  portion  of  the 
abdominal  cavity;  in  ascites  the  most  depending  portion  of 
the  abdomen  is  always  flat,  the  percussion  resonance  being 
confined  to  the  epigastric  and  umbilical  regions.  Third,  in 
ovarian  droj)sy,  the  relative  line  of  flatness  and  resonance  is 
not  altered  by  change  in  the  posture  of  the  patient,  which  is 
not  the  case  in  ascites. 

Hydatids  of  the  omentum  form  a  class  of  tumors  which  you 
will  be  unable  by  physical  signs  to  distinguish  fi'om  ovarian 
tumors.  The  fact,  however,  that  these  omental  enlargements 
are  fii'st  noticed  above  the  umbiUcus  and  gradually  enlarge 
downwards,  while  ovarian  are  fii'st  noticed  low  down  in  the 
abdomen  and  gradually  enlarge  upwards,  will  in  most  cases  be 
sufficient  for  a  diagnosis. 

Faecal  accumulations  in  the  large  intestines  may  be  mis- 
taken for  ovarian  tumors;  the  pecuUar  feel  of  such  tumors 
as  has  akeady  been  described  wiE,  however,  enable  you  to 
distinguish  them  from  ovarian  tumors. 

Abdominal  Aneurism. — Aneui-ism  of  the  abdominal  aorta 
usually  occurs  at  or  near  that  portion  of  the  vessel  fi'om  which 
the  ccehac  axis  is  given  off,  and  the  rupture  is  usually  in  the 


ABDOMINAL  ANEURISM.  I53 

posterior  wall  of  the  artery.  Aneurism  of  the  coeliac  axis,  of 
the  renal,  hepatic,  superior  mesenteric,  or  splenic  arteries  is 
of  very  rare  occurrence,  and  there  are  no  means  by  wliich,  if 
they  do  occur,  they  can  be  distinguished  from  aneurism  of  the 
abdominal  aorta. 

Inspection.— On  inspecting  the  abdomen  in  a  case  of  ab- 
dominal aneurism,  a  tumor  in  the  epigastrium  with  an  expan- 
sive impulse,  usually  may  be  discovered  ;  in  some  cases,  how- 
ever, the  closest  inspection  reveals  nothing  abnormal.  When 
a  tumor  is  present,  the  surface  of  the  abdomen  over  it  will  be 
rounded  and  smooth.  "When  the  aneurism  is  of  large  size 
abdominal  respiration  may  be  diminished  and  thoracic 
increased.  Enlargement  of  the  superficial  veins  of  the  ab- 
domen, and  oedema  of  the  lower  extremities,  are  very  rare 
phenomena. 

Palpation. — By  palpation  we  can  determine  approximately 
the  size  of  the  tumor,   its  position,  and  its  impulse. 

Aneurisms  of  the  abdominal  aorta  are  usually  felt  on 
the  median  line,  or  to  the  left  of  it,  on  the  right  side,  or  on 
both  sides.  They  are  immovahle.  The  impulse,  if  one  exist, 
is  systohc  and  expansive,  although  when  it  is  situated  high 
up,  there  also  may  be  a  slight  diastolic  movement.  A  thrill 
is  rarely  perceptible.  By  comparing  the  pulsation  in  the 
arteries  of  the  lower  extremities  with  that  of  the  uj)j)er,  a 
feebleness  of  pulsation  may  be  detected.  The  surface  of  the 
tumor  when  unruptured  is  rounded  and  smooth.  Effusions 
of  blood  into  the  surrounding  tissues  may  produce  lobula- 
tions. 

Percussion. — Dulness  or  flatness  will  exist  over  the  tumor, 
although  intestinal  tympanitic  tenderness,  etc.,  may  interfere 
with  the  value  of  this  means  of  diagnosis. 

Auscultation. — A  systolic  murmur,  resembling  that  pro- 
duced in  aneurisms  of  the  thoracic  aorta,  is  usually  heard  di- 
rectly over  the  tumor  in  front,  or  opposite  to  it,  along  the 


154  PHYSICAL  DIAGNOSIS. 

lumbar  spine  ;  rarely,  if  ever,  is  a  diastolic  murmur  heard, 
though  a  prolonged  second  sound  often  exists.  In  some  cases 
the  murmur  is  audible  when  the  patient  is  in  the  recumbent 
posture,  but  disappears  when  he  assumes  an  erect  posture. 
In  other  cases  aU  the  physical  signs  of  aneurism  are  absent, 
and  still  we  are  led  to  suspect  its  existence  from  the  rational 
symptoms,  the  most  prominent  of  which  is  a  continuous, 
deep-seated,  and  at  times  paroxysmal  pain  in  the  lumbar  re- 
gion, which  shoots  down  the  thighs  and  around  the  abdomen. 
Abdominal  aneurism  may  be  mistaken.  First,  for  en- 
largement of  various  organs  which  by  its  size  it  has  dis- 
placed, as  the  liver,  kidney  (especially  the  left),  and  the  spleen. 
The  presence,  however,  of  the  physical  signs  of  aneurism  m 
such  cases  will  enable  us  to  refer  the  apparent  enlargement  to  its 
right  source.  Second,  for  neuralgia,  rheumatism,  cohc,  renal 
calculus,  etc.  The  steady,  persistent,  long-continued,  parox- 
ysmal pain  in  the  lumbar  region,  especially  in  male  subjects,  is 
strong  presumptive  evidence  of  aneurism,  and  if  we  have  con- 
nected with  this  an  immovable,  although  perhaps  not  pulsa- 
tile tumor  along  the  course  of  the  artery,  the  diagnosis  of 
aneurism  becomes  almost  positive.  Third,  for  disease  of  the 
spine.  Here  the  pain  and  possibly  a  curvature  produced  by  an 
aneurism  may  mislead,  but  the  physical  signs  of  aneurism  in 
most  cases  will  correct  the  mistake.  Fourth,  for  psoas  or 
lumbar  abscess.  In  this  the  shape  of  the  tumor  is  elongated, 
and  there  is  neither  impulse  nor  murmur  perceptible,  which 
latter  usually  occurs  even  in  those  secondary  tumors  due  to 
rupture  of  an  aneurism  when  it  appears  in  the  lumbar  region 
or  even  at  Poupart's  ligament.  Fifth,  for  aortic  pulsation. 
In  aortic  pulsation  there  is,  however,  absence  of  a  murmur,  of 
a  thrill,  of  percussion  duhiess,  and  the  impulse  is  quick  and 
jerking,  and  not  expansive  as  in  aneurism.  Sixth,  for  abdom- 
inal tumors.  The  tumors  which  are  apt  to  be  mistaken  for 
aneurism  are,  enlarged  left  lobe  of  hver,  cancer  of  the  py- 


MESENTERIC  ENLARGEMENTS.  I55 

lorus,  enlarged  mesenteric  glands,  fsecal  accumulations,  and 
hydro  or  pyo-nepliritic  kidney.  In  tumors  the  feel  is  usually 
harder,  the  impulse  Hfting,  rarely  expansive,  and  they  may  be 
accompanied  by  ascites,  oedema,  or  enlarged  abdominal  veins, 
the  infrequency  of  which  in  aneurism  has  already  been  alluded 
to.  If  a  murmur  occur  with  a  non-aneurismal  tumor,  it  may 
be  made  to  disappear,  in  most  instances,  by  causing  the  patient 
to  assume  a  posture  on  his  hands  and  knees,  and  the  impulse 
may  be  diminished,  or  cease  at  the  same  time.  Tumors  are 
also  usually  movable,  aneurisms  immovable.  In  many  cases 
of  abdominal  aneurism,  the  diagnosis  is  uncertain. 

Omental  Tumors. — The  omentum  may  be  the  seat  of  a 
hydatid  cyst,  of  cancer,'  or  of  tubercular  deposits.  These 
deposits  or  growths  give  rise  to  tumors  which  are  readily 
detected  through  the  abdominal  walls,  both  by  percussion  and 
palpation ;  they  are  first  recognized  high  up  in  the  abdominal 
cavity,  above  the  umbilicus,  and  gradually  extend  downwards. 
If  there  are  no  adhesions,  you  can  push  the  tumors  upwards, 
and  from  right  to  left ;  they  are  superficial,  and  then*  uneven 
surface  is  readily  detected  by  passing  the  hand  lightly  over 
the  surface  of  the  abdomen.  They  are  always  more  or  less 
tender  on  firm  pressure.  The  percussion  sound  ehcited  over 
these  tumors  is  never  flat,  but  has  a  tympanitic  quality,  caused 
by  the  subjacent  intestines. 

Mesenteric  Enlargements  occupy  a  position  correspond- 
ing to  that  of  the  small  intestines.  They  are  beyond  the 
reach  of  physical  diagnosis,  except  as  they  occur  in  children, 
in  the  last  stage  of  tabes  mesenterica  ;  then  their  diagnosis  is 
of  little  practical  use,  their  cure  being  hopeless. 


INDEX. 


A. 

Auscultation,  metliods  of,  33. 

rules  for  performance  of,  33,  34. 
in  pregnancy,  148. 
Asthma,  physical  signs,  52. 
Aneurisms,  thoracic,  112. 

physical  signs  of,  112,  113, 

114. 
differential  diagnosis,  115. 
arteria  innominata,pliysical  signs, 

116. 
abdominal,  seat  of,  152. 
physical  signs  of,  153. 
differential  diagnosis,  154. 
Abdomen,  difficulties  in  physical  ex- 
ploration, 119. 
topography  of,  120. 
contents  of  various  regions,  122. 
methods  of  physical  exploration, 

128. 
inspection,  123. 
mensuration,  124. 
palpation,  124. 
percussion,  125. 
auscultation,  126. 
Abteby,   pulmonary,    relative    posi- 
tion, 81. 


B. 

Bronchitis,  simple  acute,  physical 
signs,  55. 
capillary,  physical  signs,  56. 
Bronchi,  dilatation  of,  physical  signs, 

56,  57. 
Bronchophony,  52. 
Bile  ducts,  obstruction  of,  physical 

signs,  136. 
Bladder,  physical  examination,  145. 


C. 

Cough,  resonance  of,  54. 

cavernous,  54. 

bronchial,  54. 

amphoric,  54. 
Click,  mucous,  47. 


D. 

Diagnosis,  physical,  definition,  9. 
methods  of,  9. 


E. 

Expiration,  prolonged,  39. 

Egophony,  52. 

Emphysema,     pulmonary,    physical 

signs,  57,  58. 
Empyema,  physical  signs,  58. 


Fremitus  vocal,  normal,  19. 
increased,  20. 
diminished,  20. 
absence  of,  20. 
friction,  20. 
rhoncial,  20. 


G-. 

Gurgles,  46. 

Gangrene,     pulmonary,      physical 
signs,  62. 


H. 

Hemorrhage,  pulmonary,   physical 

signs,  63. 
Hydro -pneumo- thorax,     physical 

signs,  70,  71. 
He^uit,  normal  relations,  79. 
surface  measurements,  80. 
valves,  relative  position,  80. 
phvsiological  action,  81,  82,  83, 

84,  85,^86. 
methods  of  physical  examination, 

87. 
inspection,  87,  88. 
palpation,  88. 
percussion  in  health,  89. 
auscultation,  rules  for  perform- 
ing, 90. 


158 


INDEX 


Heakt,  normal  sounds,  elements  of,90. 
mechanism,  91. 
modifications  of,  93. 
increase  of  intensity,  93. 
alterations    in    quality 

and  pitch,  93. 
alterations  in  seat,  93. 
in  rhythm,  93. 
irregularity  in,  93. 
Impulse,  diminution  of,  88. 
increase  of,  88. 
change  in  situation,  88. 
hypertrophy,  physical  signs,  110. 
dilatation,  physical  signs,  111. 
fatty      degeneration,       physical 
signs,  112. 
Hepatitis,  acute,  physical  signs,  136. 


I. 


Inspection,  definition,  16. 
in  pleurisy,  17. 

pulmonary  emphysema,  18. 
phthisis  pulmonalis,  18. 
membranous  croup,  18- 
Intestines,  normal    condition,  per- 
cussion, 129. 
abnormal      condition,     physical 
signs,  130. 

K. 

KrDNEYS,  normal  boundaries,  143. 
enlargement,  physical  signs,  143, 

144. 
differential  diagnosis,  144. 
movable,  physical  signs,  145. 


Lartngophony,  50. 

Liver,  normal  boundaries,  131. 

displacements,  133. 

fatty,  pliysical  signs,  134. 

waxy,  physical  signs,  134. 

hydatid  tumors  of,  134. 

abscess  of,  135. 

congestion  of,  136. 

cancer  of,  physical  signs,  137. 

cirrhosis  of,  physical  signs,  137. 

atrophy  of,  138. 

differential  diagnosis,  138,  139. 
Lung,  cancer  of,  physical  signs,  63. 


M. 

Mensuration,  rules  for  performing, 
20. 


Murmurs,  definition  of,  95. 
valvular,  97. 

mechanism  of,  98. 
rhythm,  rules  for  determin- 
ing, 97,  98,  99. 
seat,  rules  for  determining, 

101. 
area  of  mitral,  102. 
tricuspid,  103. 
pulmonic,  103. 
aortic,  103. 
rules  for  diagnosis,  104, 105. 
table  of,  100. 

Dr.  Cammann's  rules  in  rela- 
tion to,  106,  107,  108. 
anaemic,  functional,  and  venous, 
106. 
Mesentery,  enlargements,  physical 
signs  of,  155. 


o. 

CEdema,  pulmonary,  physical  signs, 

62. 
Ovaries,  normal  position,  149 

tumors  of,  physical  signs,  150, 151. 
differential     diagnosis,    151, 
152. 
Omentum,  tumors  of,  physical  signs, 
155. 


P. 

Placental  bruit,  definition,  146. 
area  of,  147. 


R. 

Eegions,  anterior,  posterior,  and  lat- 
eral, 10. 

clavicular,  supra  and  infra  clavic- 
ular, 10. 

mammary  and  infra-mammary, 
11, 12. 

sternal,  supra,  upper  and  lower, 

12,  13. 

scapular,  supra,  infra  and  inter, 

13,  15. 

axillary,  and  infra-axiUary,  15. 
Eespiratory  sounds,  elements  of, 

34. 
Respiration,  vesicular,  35. 

laryngeal,  trachial,  36. 

bronchial,  36,  40. 

exaggerated,  feeble,  37. 

suppressed,  interrupted,  38. 

rude,  cavernous,  amphoric,  39, 
40. 


INDEX. 


159 


Raxes,  definition,  42. 
sibilant,  43. 
sonorous,  44. 

crepitant  and  sub-crepitant,  45. 
mucous,  4G. 
Resonance,  vocal,  normal,  50. 

diminished,  exaggerated, 
50,  51. 


S. 

Stethometer,  Dr.  Quain's,  21. 
SpmoMETER,  Dr.  Hutchinson's,  22. 
Stethoscopes,  varieties,  32. 
SuccussiON,  rules  for  performing,  22. 
Sounds,  adventitious,  42. 

pericardial,  friction,  varieties  of, 

95,  96. 
foetal  heart,  definition  of,  147. 
area  of,  148. 
Souffle,  funic,  147. 
Stomach,  inspection,  palpation,  and 
percussion,  128. 
distention     of,    physical     signs, 

129. 
cancer  of,  physical  signs,  129. 
Spleen,  normal  boundaries,  139. 
percussion  of,  140. 
enlargement  of,  physical  signs, 
141. 


Spleen,   differential  diagnosis,  141, 
142. 


T. 

Tracheophony,  50. 
Tinkling,  metallic,  54. 
Thrill,  purring,  88. 


u. 

Uterus,  normal    state    of,  physical 
signs,  145. 
auscultation,  rules  for  perform- 
ing, 146. 
tumors  of,  physical  signs,  149. 


V, 

Voice,  auscultation  of,  50. 
amphoric,  52. 


w. 

Whisper,  normal,  bronchial,  and  ex- 
aggerated, 53. 
cavernous,  amphoric,  53. 


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